UNIVERSITY  OF  CALIFORNIA 
""FORNIA  COLLEGE  OF  MEDICINE 


I  8  1971 

IRVINE,  CALIFORNIA  92664 


JPRAINS; 

THEIR 

CONSEQUENCES  AND  TREATMENT 


BY 

C.  W.  MANSELL  MOULLIN, 

M.A.,  M.D.  OXON.,  F.R.C.S.  ENC;. 

Assistant  Surgeon  and  Senior  Demonstrator  of  Anatomy  at  the  London  Hospital ;  formerly 
Radcliffe  Traveling  Fellow  and  Fellow  of  Pembroke  College,  Oxford. 


REPRINTED  FROM  WOOD'S  MEDICAL  AND  SURGICAL  MONOGRAPHS. 


NEW  YORK 

WILLIAM  WOOD  &  COMPANY 
1891 


•WE/IS 


CONTENTS. 


INTRODUCTION.  PAGE 

General  Considerations, 5 

CHAPTER  I. 
The  Anatomy  of  Joints, 9 

CHAPTER  II. 
Cause  arid  Prevention  of  Sprains, 18 

CHAPTER  III. 
Diagnosis, 30 

CHAPTER  IV. 
Nature  of  the  Injury, 40 

CHAPTER  V. 
Inflammation  and  the  Process  of  Repair,  .....  60 

CHAPTER  VI. 
Imperfect  Recovery, 71 

CHAPTER  VII. 
Treatment.  Cold.  Heat.  Pressure, ,  82 

CHAPTER  VIII. 
Treatment.  Rest, ,  .  97 

CHAPTER  IX. 

Forcible  Manipulation, -        -        -        .        10& 

CHAPTER  X. 
Massage, •  120 

CHAPTER  XI. 
Sprains  of  Tendons, 133 


3/3 


iv  Contents. 

CHAPTER  XII.  PAGE 

Sprains  of  the  Back  and  Neck, 152 

CHAPTER  XIII. 

Internal  Derangement  of  the  Knee, 172 

CHAPTER  XIV. 
Contraction  of  the  Fingers, 179 

CHAPTER  XV. 
Muscular  Contraction, 187 

CHAPTER  XVI. 
Muscular  Wasting, 201 


SPRAINS 

AND  THEIR  CONSEQUENCES. 


INTRODUCTION. 

IT  has  been  my  endeavor  in  the  following-  pages  to  confine 
myself  as  closely  as  possible  to  the  commoner  forms  of  sprains, 
and  to  those  after  consequences  which  may  be  regarded  as 
directly  and  immediately  dependent  on  them.  Of  those  which 
follow  more  remotely  there  is  no  end,  and  the  briefest  descrip- 
tion would  lead  me  far  beyond  the  limits  at  my  disposal.  It 
has  been  said,  and  not  untruly,  that  in  all  probability  half  the 
crippled  limbs  and  stiffened  joints  that  are  met  with  every 
day,  date  their  starting  point  from  the  occurrence  of  some 
apparently  trivial  accident  of  this  description. 

The  question  of  treatment  has  been  dealt  with  at  some 
length ;  and  if  I  have  seemed  to  advocate  the  adoption  of  more 
active  measures  than  those  generally  employed,  especially  in 
the  case  of  long  standing  inability,  it  is  only  that  I  am  firmly 
convinced  of  their  efficacy  and  safety  when  properly  carried  out. 

Few  injuries  are  treated  with  so  little  consideration  as 
sprains.  It  is  impossible  to  overlook  wounds,  owing  to  the 
bleeding  and  pain  that  accompany  them.  Fractures,  it  is  un- 
derstood, require  rest  and  care ;  but  sprains,  in  which  the  tis- 
sues are  torn  to  such  a  degree  that  the  damage  is  far  more 
serious  than  in  many  fractures,  merely  because  they  are  so 
common,  are  considered  of  little  or  no  consequence. 

It  counts  for  nothing  that  the  part  injured  is  one  of  the 
most  complicated  structures  in  the  body,  and  particularly 
liable  to  inflammation  from  the  constant  use  to  which  it  is 
subjected.  The  construction  of  a  bone  is  comparatively  simple, 
and  its  function  is  merely  the  passive  duty  of  support.  A 


6  Sprains;  their  Consequences  and  Treatment. 

joint,  on  the  other  hand,  is  exceedingly  complex,  and  must 
4W*iy^De"asslirong1  for  support  as  the  bones  between  which  it 
lies,  but  must,  (In  addition,  be  capable  of  executing-  rapid  and 
often  extensive  movements.  Two,  three,  or  even  more  bones 
may  enter  into  its  construction;  each  of  them  where  it  forms 
part  of  the  joint  is  faced  with  cartilage;  around  them  is  a 
protecting  capsule  of  fibrous  tissue,  lined  with  a  delicate  se- 
creting membrane;  ligaments  of  different  kinds  hold  the  bones 
together;  muscles  of  various  size  and  strength  move  them  one 
on  the  other;  there  is  a  very  large  supply  of  blood-vessels  and 
nerves;  and  even  the  tissues  round  are  so  adjusted  to  the  sur- 
faces that  with  every  change  in  position  they  fill  up  the  con- 
stantly-varying spaces  round  and  between  the  bones.  Yet  a 
fracture  is  regarded  as  very  serious;  a  sprained  joint  as  quite 
a  trivial  matter. 

In  the  one  the  injury  is  simple  and  definite  in  its  character; 
one  broken  bone  does  not  differ  very  materially  in  this  respect 
from  another;  in  the  other  there  is  no  limit  to  the  variety  of 
hurt  sustained,  or  to  the  complications  that  follow.  The  liga- 
ments may  be  torn  across,  or  wrenched  off  the  bone ;  the  mus- 
cles may  be  lacerated ;  the  tendons  displaced  bodily  from  their 
grooves;  the  discs  of  cartilage  which  are  present  in  some  joints 
between  the  bones,  forced  out  from  their  position;  the  joint 
cavity  filled  with  blood,  and  so  much  more  extravasated  into 
the  tissues  that  the  discoloration  may  reach  from  the  ankle  to 
the  knee;  in  short,  the  tissues  may  be  torn  and  bruised  as  ex- 
tensively as  in  a  dislocation.  In  many  cases  the  injury  is  to 
all  intents  and  purposes  the  same;  the  sole  difference  is  that 
the  bones  which  were  wrenched  apart  at  the  time  of  the  acci- 
dent resume  their  normal  relation  to  each  other  in  the  one, 
while  in  the  other  they  either  remain  fixed,  or  slip  a  little 
further  aside.  Vidal  de  Cassis  appreciated  this  when  he  spoke 
of  sprains  as  temporary  dislocations. 

There  is  no  end  to  the  variety  of  the  injuries  that  are 
classed  together  under  this  name.  It  is  almost  an  impossi- 
bility for  two  sprains  to  be  exactly  alike.  Joints  differ  from 
each  other  as  widely  as  they  can,  both  in  structure  and  action : 
different  kinds  of  tissue  enter  into  their  formation,  and  serve 
as  many  separate  purposes;  the  violence  that  causes  the  acci- 
dent is  different  in  every  case,  both  in  its  force  and  direction; 
and  the  position  of  the  limb  at  the  moment  can  rarely  be  the 


Sprains ;  their  Consequences  and  Treatment.  7 

same.  Some  joints  are  much  more  liable  to  injury  than  others, 
those  especially  in  the  lower  limb;  and  the  ankle  more  than 
the  hip  or  knee.  In  some  the  stress  falls  on  the  ligaments; 
in  others,  as  in  the  shoulder,  on  the  muscles;  very  often  both 
suffer  together,  though  in  varying  proportion ;  or  without  the 
joint  itself  being  injured,  the  muscles  and  tendons  may  be 
strained,  and  give  rise  to  stiffness  or  weakness  that  lasts  for 
years. 

Other  considerations  also  step  in  and  help  to  make  the 
variety  greater.  No  two  persons  ever  resemble  each  other 
exactly;  even  if  this  were  possible  in  the  earliest  years  of  life, 
age,  habits,  occupation,  mental  temperament,  bodily  constitu- 
tion, and  many  other  things,  induce  such  modifications  that 
the  slightest  difference  must  at  length  become  immense.  Re- 
pair is  not  carried  on  with  the  same  degree  of  energy  in  all ; 
in  some  complications  occur  much  more  easily  than  they  do  in 
others;  inflammation  breaks  out  more  readily,  or  other  troubles 
make  their  appearance;  so  that,  even  if  by  some  strange  chance 
the  injuries  were  identically  the  same  in  any  two  cases,  it  is 
impossible  for  them  to  continue  so  for  any  length  of  time.  In 
this  respect  peculiarities  of  constitution  are  of  great  signifi- 
cance; in  the  majority  of  instances  the  ultimate  result,  whether 
the  joint  recovers  within  a  reasonable  period,  or  remains  cold, 
stiff,  and  untrustworthy  for  years,  depends  much  more  on 
them,  and  on  the  method  of  treatment  adopted,  than  on  the 
mere  fact  of  a  ligament  having  been  torn  or  only  stretched. 

This,  however,  is  not  the  only  reason  why  sprains  do  not 
merit  the  neglect  with  which  they  are  so  often  treated.  Im- 
perfect recovery  in  the  case  of  a  broken  bone  is  quite  excep- 
tional. Failure  of  union  does  sometimes,  but  very  rarely, 
occur.  It  is  more  common  for  the  position  of  the  broken  ends 
to  be  faulty,  so  that  there  is  some  deformity,  or  loss  of  power ; 
but  even  when  this  does  happen  the  after-trouble  or  incon- 
venience is  only  of  a  temporary  character,  and  at  the  end  of  a 
few  weeks  or  months,  at  the  most,  the  limb  is  as  strong  and 
firm  as  ever.  Such  a  thing  as  yielding,  weakness,  or  continued 
pain  at  the  seat  of  fracture  is  almost  unknown,  unless  there 
is  some  exceptional  condition  of  things  present.  It  is  not  so 
with  sprains.  An  amount  of  the  thickening  round  the  seat  of 
injury,  so  slight  as  altogether  to  escape  notice  in  the  case  of 
a  fracture,  is  quite  enough  to  disable  a  joint. 


8  Sprains ;  their  Consequences  and  Treatment. 

It  is  true  that  a  large  number  of  sprained  joints  get  well 
of  themselves,  or  under  ordinary  domestic  treatment,  a  few, 
it  must  be  admitted,  in  spite  of  it;  but  even  in  the  young-  and 
healthy,  it  is  not  unusual  to  find  the  action  of  the  joint  seri- 
ously impaired.  There  may  be  merely  a  general  sense  of 
weakness  and  insecurity,  a  feeling-  that  it  is  not  to  be  trusted 
as  it  was  before ;  or  the  least  attempt  at  movement  may  be 
attended  with  intolerable  suffering.  There  may  be  no  very 
visible  or  definite  alteration,  or  every  tissue  of  which  the  joint 
is  composed  may  be  more  or  less  disorganized.  The  skin  may 
be  exquisitely  tender;  the  subcutaneous  tissues  swollen  and 
distended,  so  that  the  natural  outline  cannot  even  be  recog- 
nized; the  muscles  may  waste  away;  the  tendons  become 
glued  to  their  sheaths,  and  the  interior  of  the  joint  be  dam- 
aged to  such  an  extent  that,  even  if  everything  else  were  re- 
stored, it  would  be  impossible  for  the  bone  to  work  evenly  or 
smoothly  on  the  other. 

Results  of  this  kind,  happily,  may  nearly  always  be  pre- 
vented. It  is  true  that  in  some  people  the  power  of  repair  is 
much  more  feeble  than  it  is  in  others;  and,  no  doubt,  under 
some  conditions,  such  as  advancing  age,  joints  are  especially 
prone  to  stiffness  and  other  troubles;  but  taking  them  as  a 
whole,  few  kinds  of  accidents  are  more  amenable  to  treatment 
than  sprains,  if  only  two  conditions  are  observed :  one,  that  it 
is  commenced  sufficiently  early;  the  other,  that  it  is  carried 
out  thoroughly  and  efficiently,  not  in  a  perfunctory  manner. 

Afterwards,  if  the  time  immediately  after  the  accident  has 
been  allowed  to  pass  by,  and  the  joint  is  stiff,  and  recovery 
imperfect,  a  great  deal  may  still  be  done ;  but  as  a  rule,  the 
longer  the  delay  the  more  remote  the  prospect  of  perfect 
restoration.  The  sudden  and  startling  cures  that  are  so  often 
heard  of  are  really  few  and  far  between.  It  must  always  be 
remembered  that  in  surgery,  as  in  most  other  things,  successes 
are  trumpeted  abroad,  and  always  quoted  as  an  encourage- 
ment, while  failures  are  either  never  heard  of,  or  quite  uncon- 
sciously are  forgotten.  Much  more  often  recovery  is  slow  and 
tedious,  requiring  care  and  much  patience,  with  days  in  which 
improvement  is  well  marked,  interspersed  among  a  much 
larger  number  on  which  either  no  change  at  all  is  apparent, 
or  possibly  even  the  pain  and  stiffness  seem  actually  worse. 


OHAPTEE  I. 

THE  ANATOMY  OP  JOINTS. 

THERE  is  no  need  in  a  work  of  this  kind  to  enter  into  a  de- 
tailed account  of  the  structure  of  joints,  or  to  describe  minutely 
the  different  varieties.  I  shall  only  mention  a  few  particulars 
to  which  it  seems  advisable  to  call  attention,  as  the  clinical 
symptoms  that  follow  injuries  do  not  always  correspond  with 
the  structures  as  described  in  ordinary  anatomical  treatises. 

A  joint  is  the  connecting-  link  between  two  of  the  rigid 
parts  of  the  skeleton.  Both  in  the  trunk  and  in  the  limbs  the 
main  support  runs  down  the  centre  like  an  axis,  and  for  the 
sake  of  mobility  is  divided  into  rig-id  and  flexible  segments. 
The  latter  are  known  as  joints. 

Yielding  Joints. — Some  are  very  simple.  There  is  merely 
a  toug-h  layer,  made  up  partly  of  fibrous  tissue,  and  partly  of 
cartilag-e,  uniting-  the  two  bones,  and  allowing-  a  limited  amount 
of  bending  to  take  place  between  them  in  all  directions.  Bone 
and  fibre-cartilage  are  developed  from  the  same  material;  in 
one  part  lime  salts  are  deposited,  so  that  it  becomes  hard  and 
dense ;  in  another  fibres  make  their  appearance,  and  it  is  con- 
verted into  ligamentous  tissue,  capable  of  bending  with  ease 
from  side  to  side,  but  admirably  adapted  to  resist  longitudinal 
strain.  The  two  are  quite  continuous,  and  shade  off  imper- 
ceptibly into  each  other.  So  slight,  indeed,  is  the  difference, 
that  it  not  unfrequently  happens,  as  a  result  of  disease,  or 
even  of  old  age,  that  the  whole  becomes  converted  into  bone, 
and  the  joint  disappears  as  such. 

Others  are  a  little  more  complicated;  but  the  changes  that 
make  their  appearance  during  normal  growth,  or  at  certain 
special  periods,  show  plainly  that  the  difference  between  them 
and  the  more  complex  ones  is  only  one  of  degree,  and  not  one 
of  kind.  The  ends  of  the  bones,  if  carefully  examined,  are  a 
little  expanded,  so  as  to  form  a  wider  surface  for  the  attach- 
ment of  the  uniting  disc;  while  the  sides  are  cut  away  to  lessen 


IO  Sprains;   their  Consequences  and  Treatment. 

the  weight  and  to  economize  material.  At  the  same  time  the 
softer  intermediate  part  becomes  modified.  Owing  to  the 
varied  character  of  the  strains  that  fall  on  its  sides  and  centre, 
they  become  different  in  texture  and  in  power  of  resistance. 
The  centre,  where,  whatever  the  direction  in  which  one  bone 
is  bent  on  the  other,  there  must  always  be  pressure  with  but 
little  tendency  to  separation,  remains  cellular,  or  becomes  so 
soft  and  yielding  that  in  some  cases  it  is  almost  fluid.  At  the 
circumference,  where  in  every  strain  there  is  compression  on 
the  concave  side  and  tension  on  the  convex,  the  connecting 
medium  gradually  becomes  more  and  more  fibrous,  until  by 
degrees  the  originally  uniform  layer  of  fibro-cartilage  is  re- 
solved into  a  central  cavity  surrounded  by  a  fibrous  capsule 
and  separated  from  the  surfaces  of  the  bones  by  a  layer  of 
cartilage  which  undergoes  no  alteration. 

Such  are  the  joints  in  the  backbone  between  the  bodies  of 
the  vertebrae,  though  in  them,  at  least  in  man,  the  change 
rarely  progresses  so  far.  The  union  is  exceedingly  strong; 
the  amount  of  movement  allowed  at  each  very  limited,  though 
it  may  take  place  in  any  direction ;  and  the  aggregate  result 
of  a  number  close  together  is  very  considerable. 

They  are  very  rarely  sprained;  their  strength,  their  posi- 
tion close  together,  so  that  any  stress  falling  on  one  is  dis- 
tributed over  a  large  number,  and  the  limited  range  of  move- 
ment, prove  their  safeguard.  If  the  violence  is  so  extreme 
that  something  must  give  way,  they  either  tear  across  or 
separate  from  the  bone  on  one  side.  Then  the  injury  is  to  all 
intents  and  purposes  a  fracture,  and  like  fractures  is  repaired 
by  the  deposition  of  bony  material,  so  that  the  joint  is  lost. 

Movable  Joints. — It  is  only  a  step  from  joints  such  as  these 
to  those  in  which  there  is  a  well-defined  central  space,  enclosed 
in  a  fibrous  capsule,  and  lined  with  a  delicate  secreting  mem- 
brane. The  development  of  the  various  parts  is  carried  further 
and  further,  until  they  differ  from  each  other  widely  in  ap- 
pearance; but  the  degree  of  relationship  between  them  is  as 
near  as  ever  it  was;  and  they  are  as  much  connected  together, 
and  as  closely  bound  up  with  each  other,  as  they  were  before 
the  change.  The  difference  is  only  one  of  degree,  not  one  of 
kind.  They  become  varied  in  outward  appearance  and  physi- 
cal properties,  because  of  the  different  services  they  have  to 
perform ;  but  they  never  lose  their  mutual  sympathy  or  con- 


Sprains ;  their  Consequences  and  Treatment.  1 1 

nection.  It  is  impossible  for  one  part  of  a  joint  to  be  injured, 
or  to  suffer  in  any  way,  without  influencing1  the  rest.  Joints 
are  not  built  up,  like  machinery,  of  different  and  separate 
parts,  any  one  of  which  can  be  injured  and  replaced  without 
interfering-  with  the  others;  they  are  living  organs,  which 
cannot  be  healthy  if  the  smallest  part  fails  in  its  duty. 

The  Bones. — In  the  limbs  and  the  more  movable  joints  the 
modifications  are  especially  great.  First,  the  bones,  which  are 
the  chief  supporting  structures,  become  more  highly  special- 
ized. Instead  of  retaining  the  same  uniform  character  the 
ends  are  altered  in  one  direction,  the  middle  in  another.  The 
shaft  becomes  hollowed  out  and  assumes  a  cylindrical  form, 
the  shape  well  known  to  mechanicians  as  the  one  best  calcu- 
lated to  withstand  vertical  pressure  and  lateral  strain  with 
the  minimum  expenditure  of  material.  Here  and  there  the 
compact  walls  are  strengthened  by  outlying  ridges,  so  that 
the  cross  section  in  some  is  almost  prismatic.  The  ends,  on 
the  other  hand,  become  wide  and  expanded,  to  increase  the 
extent  of  surface  that  enters  into  the  formation  of  the  joint; 
often  they  are  still  further  enlarged  by  processes  jutting  out 
to  afford  greater  strength  and  security  for  the  ligaments  that 
hold  them  together,  and  more  advantageous  leverage  for  the 
muscles  that  move  them.  At  the  same  time  the  internal 
structure  loses  its  uniform  arrangement.  Where  the  range 
of  movement  is  limited  and  equal  in  all  directions,  the  inter- 
lacing network  of  bony  spicules,  of  which  the  sponge-like  in- 
terior is  formed,  shows  no  well-defined  differences  either  in 
density  or  arrangement.  The  outer  layer  is  merely  a  little 
more  compact  and  smooth  on  the  surface  than  the  rest.  In 
the  more  highly  developed  joints,  no  matter  in  what  direction 
the  bones  are  sawn,  the  dense  tissue  that  forms  the  outer 
layer,  and  the  open-work  interlacing  bars  inside,  are  always 
so  arranged  in  arches  and  curves  as  to  diffuse  as  far  as  possi- 
ble over  the  whole  the  pressure  that  falls  on  any  one  spot,  and 
to  secure  the  greatest  amount  of  strength  and  elasticity  with 
the  least  weight  and  the  smallest  expenditure  of  material. 

Then  the  surfaces  in  contact  with  the  opposite  bone  become 
varied  in  direction  and  outline  in  order  to  correspond  to  the 
movements.  The  more  active  and  vigorous  these  are,  the 
more  changed  and  uneven  they  become.  In  the  simplest  joint 
they  are  flat,  and  face  each  other  directly,  only  allowing  a 


1 2  '  Sprains ;  their  Consequences  and  Treatment. 

certain  amount  of  gliding1  between  them.  In  others — the 
shoulder  and  hip,  for  example — the  extremity  of  one  bone  is 
hollowed  out  into  a  cup  into  which  the  other  fits,  more  or  less 
accurately,  according"  to  the  degree  of  support  required.  In 
the  lower  limb,  where  the  need  of  this  is  much  greater  than 
in  the  upper,  the  rounded  extremity  of  the  bone  forms  more 
than  half  a  sphere,  and  is  so  tightly  embraced  by  the  sides  of 
the  cup,  that,  even  when  everything  that  holds  the  bones  to- 
gether has  been  divided,  it  requires  very  considerable  strength 
to  pull  the  two  apart.  In  the  shoulder,  on  the  other  hand,  the 
cavity  is  shallow,  the  head  of  the  bone  large  in  comparison, 
and  the  range  of  movement  increased  thereby  at  the  expense 
of  the  security.  In  a  third  class,  the  ends  are  so  modified  with 
regard  to  each  other,  that  movement  can  only  take  place  in 
one  plane  as  on  a  hinge.  In  the  elbow,  for  example,  the  bone 
is  rounded  from  before  backwards,  and  fits  into  a  correspond- 
ing depression  on  the  other,  rotating  in  it  on  an  axis  that 
runs  from  side  to  side.  In  the  ankle  there  are  stout  project- 
ing processes,  one  on  either  side,  so  that  movement  is  strictly 
limited  to  one  direction,  and  lateral  bending  is  impossible. 

When  more  complicated  movements  are  required,  the  modi- 
fications become  greater  still.  In  one  instance  a  ligamentous 
ring  attached  at  one  side  is  thrown  round  the  neck  of  a  bone, 
so  that  it  can  turn  securely  in  it  on  its  own  axis.  In  another, 
discs  of  fibro-cartilage  are  interposed  between  the  bony  sur- 
faces to  deepen  the  sockets  and  lessen  the  impact  of  shocks ; 
or,  as  in  the  case  of  the  wrist  and  foot,  a  number  of  small 
bones  are  so  adjusted  to  each  other  that  the  pressure  falling 
on  any  one  of  them  is  diffused  and  distributed  over  all  the  rest. 

The  Fibrous  Tissue. — These  changes  are  not  confined  to 
the  bones;  in  the  more  movable  joints  the  ligaments  become 
modified  quite  as  much.  As  already  mentioned,  in  the  sim- 
plest the  fibrous  tissue  that  joins  the  bones  together  passes 
directly  from  the  surface  of  one  to  a  corresponding  point  on 
the  other.  Where  the  range  of  motion  is  a  little  more  exten- 
sive, the  part  round  the  circumference  becomes  more  fibrous, 
the  interior  softer  and  more  cellular.  In  those  which  admit  a 
wide  extent  of  movement  the  change  is  carried  further  still. 
The  soft  central  space  becomes  a  well-defined  cavity;  and  the 
fibrous  tissue  round  forms  a  firm  ligamentous  capsule,  enclos- 
ing it,  and  tying  the  two  bones  together. 


Sprains ;   their  Consequences  and  Treatment.  13 

The  Capsule. — Simultaneously  with  this  the  point  to  which 
the  capsule  is  attached  undergoes  an  alteration.  Freedom  of 
movement  is  easily  gained  lay  increasing-  the  length  of  the 
fibres;  but  at  the  same  time  stability  and  security  are  lost, 
unless,  as  in  the  case  of  the  shoulder,  the  surrounding  muscles 
replace  the  ligaments  in  checking  and  controlling  the  action. 
Accordingly,  in  all  cases  in  which  the  range  of  movement  ex- 
ceeds a  very  small  angle,  the  fibres  no  longer  pass  from  surface 
to  surface,  or  even  from  margin  to  margin,  but  are  shifted  fur- 
ther back  on  to  the  sides  of  the  bones,  so  that  the  ends  of  these 
are  enclosed  by  the  capsule  and  lie  inside  the  joint.  By  this 
arrangement  one  bone  is  enabled  to  glide  on  the  other  when 
any  stress  falls  on  it,  and  freedom  of  movement  is  gained 
without  the  sacrifice  of  strength.  There  are  few  joints  in  the 
body  admitting  of  much  angular  movement  in  which  one  joint 
does  not  glide  to  some  extent  on  the  other. 

The  Ligaments. — The  strength  of  the  fibrous  capsule  be- 
comes modified  at  the  same  time.  Where  the  amount  of 
movement  is  but  little,  and  is  equal  in  all  directions,  there  is  a 
uniform  and  even  layer,  extending  all  round  the  joint  from 
one  bone  to  the  other.  When  the  structure  of  the  bones  allows 
bending  in  one  plane  only,  as  in  true  hinge-joints,  the  side  por- 
tions springing  from  the  ends  of  the  axis  of  motion  are  more 
highly  developed  than  the  rest.  Each  is  attached  to  a  point 
on  the  more  fixed  bone,  and  radiates  from  this  in  a  fan-like 
way  on  to  the  other,  so  that  the  two  are  firmly  braced  together 
in  all  positions  of  the  limb.  At  the  back  and  front  it  is  thin 
and  loose,  merely  serving  to  protect  the  cavity  of  the  joint. 
By  steps  such  as  this  the  capsule  of  a  joint  gradually  becomes 
split  up  into  four  divisions,  which  appear  to  be  so  isolated  and 
distinct  from  each  other  that  they  are  often  called  anterior, 
posterior,  and  lateral  ligaments.  They  are  not,  however,  sep- 
arate structures  in  any  sense  of  the  term.  They  are  only  sub- 
ordinate parts  of  the  same  that  have  become  differentiated 
from  each  other  by  the  difference  in  the  character  of  the  work 
they  are  called  on  to  perform. 

In  a  ball  and  socket  joint,  which,  so  far  as  this  is  concerned, 
may  be  regarded  as  a  kind  of  universal  hinge,  the  capsule  is 
modified  in  the  same  manner.  In  the  hip,  where  unyielding 
support  in  front  is  required,  that  part  is  so  strong  that,  even 
in  dislocation,  it  very  rarely  gives  way ;  behind,  where  there 


14  Sprains ;  their  Consequences  and  Treatment. 

is  but  little  strain,  it  is  comparatively  thin  and  weak.  In  the 
shoulder,  everything-  else  is  subordinated  to  accurate  and  rapid 
action  in  all  directions.  The  capsule  consequently  is,  with  the 
exception  of  one  part,  so  loose  and  long1  that  it  only  becomes 
tense  when  the  angle  of  movement  is  extreme;  the  muscles 
here  take  the  place  of  the  ligaments  almost  entirely,  and  not 
only  execute  but  also  control  and  restrain  the  movements  of 
the  arm  with  a  precision  that  would  be  impossible  if  it  were 
dependent  on  passive  and  unyielding  fibrous  tissue. 

The  Synovial  Membrane. — The  cavity  of  a  joint  always 
contains  a  certain  amount  of  an  exceedingly  viscid  fluid,  known 
as  synovia.  The  quantity  is  very  variable  even  in  the  same 
joint,  but  in  general  there  is  merely  sufficient  to  moisten  the 
surfaces  that  are  in  contact  with  each  other,  so  as  to  avoid 
friction  as  far  as  possible.  It  is  secreted  by  a  delicate  struct- 
ure known  as  the  synovial  membrane.  This  lines  the  interior 
of  the  fibrous  capsule,  and  is  prolonged  into  all  the  outlying 
pouches  in  connection  with  it,  but  does  not  extend,  at  least  in 
the  adult,  over  the  layer  of  cartilage  that  covers  the  ends  of 
the  bones.  Before  birth  an  exceedingly  delicate  film  of  cells, 
without  an}"  fibres,  may  be  found  in  this  situation;  but  they 
are  soon  worn  off,  and  do  not  reappear.  Where  this  membrane 
is  folded  on  itself,  as,  for  example,  at  the  attachment  of  the 
capsule  to  the  bone,  it  is  often  thrown  into  folds,  which,  under 
some  circumstances,  are  capable  of  assuming  a  very  consider- 
able size.  The  inner  surface  is  smooth  and  polished ;  the  other 
is  continuous  with  the  fibrous  tissue  of  the  ligaments,  where 
they  serve  to  enclose  the  joint;  but  between  them,  and  in  the 
intervals  found  here  and  there  extending  under  muscles,  it 
possesses  a  delicate  wall  of  its  own,  formed  of  connective  tissue, 
and  connected  to  the  structures  round  by  a  few  loose  and  scat- 
tered fibres. 

This  synovial  membrane  is  in  general  regarded  as  a  sepa- 
rate and  distinct  structure,  found  in  those  joints  only  in  which 
there  is  considerable  freedom  of  movement.  In  others,  it  is 
stated  that  an  imperfect  cavity  is  sometimes  developed,  but 
that  it  is  never  lined  by  a  true  synovial  sac.  This  view  is  in- 
correct; neither  the  method  of  development  nor  the  changes 
that  take  place  in  disease  lend  it  any  support.  In  reality,  the 
synovial  membrane  is  nothing  more  than  the  lining  of  the 
cavity,  which  is  developed  as  the  amount  of  movement  in- 


^Sprains;  their  Consequences  and  Treatment.  15 

creases;  and  under  similar  conditions,  structures  indistin- 
guishable from  synovia!  sacs  may  be  developed  in  any  part  of 
the  body. 

In  the  centre  of  a  joint  the  cells  which  fill  up  the  space  be- 
tween the  bones  break  down,  become  liquid,  and  dissolve 
away;  round  the  circumference  they  persist.  The  outermost, 
as  already  mentioned,  are  converted  into  fibrous  tissues,  and 
form  the  ligaments,  or  the  capsule,  as  the  case  may  be;  the 
inner  ones,  those  that  immediately  line  the  cavity,  form  the 
synovial  membrane.  The  cartilage  on  the  ends  of  the  bones 
is  not  covered  with  it,  or  it  is  at  most  covered  with  a  single 
layer  of  cells,  because  of  the  relation  it  bears  to  the  cavity, 
and  because  there  is  no  fibrous  tissue  developed  on  its  surface. 
In  the  intervals  between  the  ligaments,  where  there  is  nothing 
to  protect  the  cavity  of  the  joint,  it  is  a  little  stronger  than 
elsewhere,  and  may  be  called  a  membrane;  but  it  is  not  an 
isolated  or  distinct  structure  here  any  more  than  it  is  else- 
where. It  is  continuous  on  either  side  with  the  neighboring 
ligaments;  where  it  comes  into  contact  with  the  cartilage  it 
shades  off  into  it,  so  that  it  is  impossible  to  say  where  one 
commences  and  the  other  ends;  and  its  outer  surface  is  part 
of  the  loose  and  delicate  connective  tissue  that  fills  in  all  the 
irregularities  round  joints,  extends  under  the  muscles  and 
tendons,  and  forms  a  layer  under  the  skin. 

Mutual  Sympathy  of  all  the  Parts. — Joints  are  commonly 
regarded  as  composed  of  many  different  structures,  all  of  them 
separate  and  distinct  from  each  other,  with  different  and  in- 
dependent functions.  There  are  ligaments  to  hold  the  bones 
together;  a  sjmovial  membrane  to  render  the  movements 
smooth;  cartilages  over  the  ends  of  the  bones  to  lessen  the 
impact  of  any  shock;  and  round  them,  filling  up  all  the  inter- 
spaces, a  quantity  of  loose  and  delicate  connective  tissue,  con- 
taining the  blood-vessels  and  nerves  which  supply  the  joint. 

This  view  may  serve  for  the  purposes  of  ordinarj7  descriptive 
anatomy;  but  it  gives  an  altogether  wrong  impression  of  the 
nature  of  the  injury  sustained  when  a  joint  is  sprained,  and  of 
the  causes  of  the  complications  and  after-troubles  that  follow 
with  such  frequency.  The  bones  that  form  a  joint,  no  matter 
how  many  there  may  be,  or  how  great  may  be  the  varieties  of 
their  shape,  are  surrounded  and  held  together  by  connective 
tissue,  which  is  structurally  continuous  with  them.  It  bridges 


1 6  Sprains ;  their  Consequences  and  Treatment. 

over  the  interval  between  them,  fills  up  all  the  interstices  left 
by  the  muscles  and  tendons,  and  forms  an  investment  for  these 
and  every  other  structure  near.  One  part,  where  there  is 
much  tension,  becomes  dense  and  unyielding,  so  that  it  is 
known  as  ligament;  in  another  the  cells  undergo  a  process  of 
liquefaction,  and  a  cavity  is  formed ;  the  limiting  wall  of  this 
is  differentiated  into  a  synovial  sac,  and  a  membrane  more  or 
less  distinct  is  developed  from  it.  The  different  structures 
lose  all  external  resemblance  to  each  other.  What  they  do 
not  lose  is  their  relationship  from  their  common  descent. 
Throughout  the  whole  of  life  the  closest  sympathy  persists 
between  them,  so  that  it  is  impossible  for  any  one  of  them  to 
suffer  by  itself.  It  follows  as  a  natural  consequence  from  this 
that  sprains  can  never  be  the  simple  things  they  are  usually 
considered,  or  be  confined  to  the  mere  stretching  or  tearing 
of  an  isolated  ligament.  The  immediate  effect  of  an  accident 
may  fall  upon  the  ligaments,  or  it  may  not;  it  can  never  be 
limited  to  them.  The  capsule  of  the  joint  is  opened  up,  the 
cartilages  bruised,  the  muscles  torn,  the  tendon  sheaths 
strained,  the  interior  filled  with  blood,  and  so  much  more  ex- 
tra vasated  into  the  tissues  round  that  the  strain  may  extend 
the  whole  way  up  a  limb,  and  may  not  disappear  for  six  weeks. 
Very  often,  in  spite  of  the  popular  belief,  the  ligaments  are 
the  part  that  suffer  least :  they  certainly  never  suffer  alone. 

Even  if  by  any  chance  they  were  the  only  structures  hurt 
at  the  moment,  it  is  impossible  for  the  other  tissues  to  remain 
unaffected  during  the  changes  attendant  on  their  repair.  A 
wheel  or  a  band  in  a  piece  of  machinery  may  be  damaged  and 
restored  without  interfering  with  the  other  parts.  When  a 
ligament  is  hurt  a  certain  amount  of  blood  escapes  into  the 
synovial  sac  and  the  spaces  round ;  all  the  vessels  dilate;  the 
synovial  folds  become  swollen;  the  joint  is  tender  to  the  touch; 
the  temperature  of  the  part  is  raised ;  its  movements  are  in- 
terfered with;  even  the  external  shape  of  the  limb  is  altered. 
Nothing  escapes ;  every  structure  round  participates  more  or 
less. 

The  same  is  true  of  the  later  troubles  that  so  frequently 
impair  the  freedom  of  movement  in  joints  long  after  they  have 
been  sprained.  The  stiffness,  for  example,  that  is  often  laid  to 
the  credit  of  a  contracted  tendon,  or  shortened  band,  is  never 
due  to  this  alone ;  nor  is  the  sense  of  insecurity  dependent  en- 


Sprains ;   their  Consequences  and  Treatment.  17 

tirely,  or  even  to  any  extent,  on  the  weakness  of  an  injured 
lig-ament.  It  is  only  by  taking-  a  wider  and  more  comprehen- 
sive view  of  the  structure  of  joints,  and  by  regarding-  them  as 
organs  of  the  body,  wonderful  in  their  complexity,  that  a  true 
conception  can  be  obtained  of  the  nature  of  the  damage  they 
suffer  in  sprains,  and  of  the  method  in  which  they  should  be 
treated,  so  as  to  avoid,  as  far  as  may  be,  the  occurrence  of 
permanent  injury. 


CHAPTER  II. 

CAUSE  AND  PREVENTION  OF  SPRAINS. 

WITHOUT  going-  so  far  as  to  say  that  sprained  joints  can 
be  entirely  prevented,  there  is  no  doubt  that  it  is  possible  to 
avoid  and  guard  against  them  to  a  very  considerable  degree. 
In  some  people  they  are  particularly  common;  and  so  they 
are  at  certain  times,  and  under  certain  conditions.  Others 
escape  in  a  manner  that  seems  almost  marvellous,  and  possess 
the  power  of  using-  their  joints  in  a  fashion  that  would  be  im- 
possible in  the  majority. 

The  Condition  of  the  Muscles. — This  depends  mainly  on 
the  condition  of  the  muscular  system.  The  strength  and  se- 
curity of  the  articulations  are  assured  in  proportion  to  the 
perfection  of  its  development.  Sprains  never  occur  unless  the 
muscles  are  either  weakened  and  tired  out  by  prolonged  ex- 
ertion, or  are  caught  unawares  by  some  sudden  slip,  before 
they  can  recover  themselves.  Astley  Cooper  said  of  disloca- 
tions that  it  was  only  possible  for  them  to  take  place  when 
the  muscles  were  unprepared  for  resistance;  otherwise  the 
greatest  force  would  hardly  produce  the  effect.  Without  say- 
ing so  much  of  sprains,  there  can  be  no  question  that  such 
accidents  rarely  happen  unless  the  muscles  that  safeguard 
the  joints  are  taken  by  surprise.  Ordinarily  speaking,  they 
are  the  result  of  a  sudden  twist,  so  rapid  that  recovery  cannot 
take  place  in  time,  and  naturally  this  is  most  likely  to  happen 
to  those  who  have  never  accustomed  their  muscles  to  much 
exertion,  or  who,  from  fatigue,  have  lost  that  instinctive  vigil- 
ance and  power  of  recovery  essential  to  the  safety  of  a  joint. 

This,  among  others,  is  one  reason  why  sprains,  especially 
of  the  knee  and  ankle,  are  so  common  among  women,  and 
those  men  who,  in  their  youth,  were  distinguished  for  athletic 
feats.  In  the  former,  the  muscles  are  insufficiently  exercised, 
so  that  they  never  attain  the  vigilance  and  instantaneous 
power  of  response  necessary  to  prevent  the  consequences  of  a 


Sprains ;   tJieir  Consequences  and  Treatment.  19 

careless  step;  in  the  latter,  with  advancing-  years  and  altered 
modes  of  life,  the  muscles  fall  out  of  training-,  without  its  being- 
perceived,  or  perhaps  sometimes  without  its  being-  acknowl- 
edged. Then  some  unusual  effort,  especially  a  prolonged  one, 
that  in  days  g-one  by  would  have  been  accomplished  easily, 
proves  too  much  for  their  endurance  under  the  altered  condi- 
tions, and  something-  gives  way.  Unhappily,  when  this  has 
taken  place  once,  the  joint  often  remains,  as  it  were,  a  weak- 
ened spot,  and  there  is  always  the  possibility  of  the  same  thing- 
happening-  again  and  again,  with  greater  ease  each  time. 

The  muscles  are  really  part  of  the  joint  as  much  as  the 
bones  or  the  synovial  membrane.  It  may  be  more  convenient 
to  describe  them  separately,  but  the  function  of  a  joint  is 
movement,  and  in  considering-  the  way  in  which  sprains  inter- 
fere with  this,  the  muscles  that  execute  and  direct  it  are  as 
much  concerned  as  the  ligaments,  which  have  only  the  passive 
duty  of  checking  it  when  it  is  excessive.  This  is  true  of  all 
joints,  but  especially  of  those  in  which  the  freedom  of  move- 
ment is  greatest,  and  which  on  that  account  are  the  most  ex- 
posed to  strains  and  injuries  of  like  character.  As  Morris  has 
pointed  out,  the  strength  of  any  single  joint,  and  its  power  of 
resisting  injury,  are  inversely  proportioned  to  its  freedom  of 
mobility. 

In  the  more  fixed  joints,  where  there  is  only  an  indistinctly 
marked  cavity  in  the  centre  of  the  fibre-cartilage,  the  muscles 
are  short  and  broad,  with  much  inelastic  fibrous  tissue  in  their 
composition,  and  often  are  so  arranged  with  cross- running  and 
interlacing  fibres  that  while  one  bone  is  moving  on  the  other 
it  is  held  even  more  firmly  in  contact  with  it  than  when  it  is 
at  rest.  Where,  on  the  other  hand,  the  range  of  movement  is 
extensive,  the  security  of  the  joint  is  often  dependent  entirely 
on  the  muscles.  In  the  shoulder,  for  example,  there  is  a  fibrous 
capsule  surrounding  the  ends  of  the  bones,  and  forming  the 
apparent  bond  of  union  between  them.  But  it  is  so  loose,  and 
has  so  little  influence  in  controlling  movements,  that  if  the 
muscles  are  paralyzed  the  arm  drops  down  for  upwards  of  an 
inch.  Here  in  particular,  owing  to  the  need  of  accuracy  and 
delicacy,  combined  with  strength  and  rapidity,  the  function  of 
controlling  the  movements  of  the  joint  is  assigned  almost  en- 
tirely to  those  structures  which  originate  them.  The  muscles 
take  the  place  of  ligaments. 


2O  Sprains ;  their  Consequences  and  Treatment. 

When  this  occurs  their  shape  and  arrangement  are  modi- 
fied. They  become  divided,  roughly  speaking1,  into  two  sets. 
Some  are  short  and  "broad,  and  immediately  surround  the 
joint.  These  maintain  the  proper  degree  of  pressure  between 
the  bones,  and  keep  the  action  smooth.  Others  are  much 
longer,  and  are  attached  to  distant  points  by  means  of  rounded 
tendons,  which  lie  in  grooves  lined  by  a  delicate  sheath.  On 
these  depend  the  vigor  and  rapidity  of  the  movements.  They 
differ  greatly  in  size  and  direction,  but  the  connection  that 
exists  between  them  and  the  joint  is  no  less  intimate;  the 
same  nerve  supplies  them  both.  They  are  really  but  different 
parts  of  the  same  mechanism,  so  closely  united  together  by 
the  bond  of  common  descent,  and  so  associated  with  each 
other  by  the  identical  nature  of  the  nerve  supply,  that  it  is 
not  possible  for  one  of  them  to  be  injured  and  the  rest  escape. 

The  same  is  true  of  the  skin  that  covers  them  in  and  pro- 
tects them.  This,  too,  is  supplied  by  the  same  nerve,  and 
when  the  joint  or  the  muscles  is  injured  cannot  help  being 
affected  at  the  same  time.  Illustrations  of  this  are  of  com- 
mon occurrence  as  the  result  of  sprains.  It  has  often  been  re- 
marked that  after  prolonged  and  severe  exertion  the  skin  over 
the  insertion  of  the  muscles,  and  in  certain  spots  over  joints, 
becomes  exquisitely  tender  from  its  sympathy  with  the  parts 
beneath.  It  does  not  arise  from  any  irritation  or  inflamma- 
tion of  the  skin  itself,  for  nothing  has  happened  to  affect  it  in 
any  way.  Yet  the  slightest  touch  gives  rise  to  the  feeling  of 
actual  pain.  Firm  pressure,  on  the  other  hand,  relieves  it, 
not,  as  is  often  said,  because  it  is  hysterical  and  imaginary, 
but  because  of  the  numbing  effect  of  compression  on  the  super- 
ficial cutaneous  nerves.  Plainly  the  skin,  which  is  an  exceed- 
ingly sensitive  structure,  is  suffering  in  sympathy  with  the 
overworked  organs  it  is  intended  to  protect. 

The  Muscles  as  Ligaments. — The  muscles,  therefore,  must 
be  considered  in  a  twofold  relation  to  the  joints.  On  the  one 
hand  they  are  the  sole  agents  for  executing  movements;  on 
the  other,  under  all  ordinary  circumstances,  they  take  the 
place  usually  assigned  to  ligaments,  and  act  as  the  main  safe- 
guard. So  long  as  the  action  is  confined  within  moderate 
limits  the  ligaments  are  entirely  unconcerned ;  they  are  merely 
passive  bands  of  inelastic  fibrous  tissue,  so  loose  as  to  have  no 
restraining  power  until  a  certain  angle  is  reached.  Then  they 


Sprains ;  their  Consequences  and  Treatment.  21 

suddenly  become  tight,  and  bring-  the  movement  to  an  abrupt 
conclusion.  The  muscles,  on  the  other  hand,  are  always  tense, 
no  matter  what  may  be  the  position  of  the  limb.  No  move- 
ment, not  even  the  bending  of  a  finger,  is  so  simple  that  it  can 
be  carried  out  by  the  action  of  a  single  set;  the  opposing  ones 
must  always  act  with  them,  so  that  the  movement  may  be 
even  and  steady,  not  disorderly  at  its  commencement,  or 
brought  to  a  sudden  standstill  at  its  close.  The  firmness  and 
security  of  the  joints — except  such  as  the  knee — in  all  their 
positions  are  entirely  due  to  the  continuous  steady  contraction 
of  opposing  groups  of  muscles.  They  are  the  agents  which 
prevent  movement  being  carried  too  far,  so  that  under  or- 
dinary conditions  strains  do  not  fall  on  rigid  and  inelastic 
ligaments.  When  from  fatigue  or  carelessness  this  does  hap- 
pen, the  ligament  may  be  strong  enough  to  resist,  but  more 
often — especially  in  the  joints  with  free  movement — it  stretches 
or  tears,  and  a  sprain  of  greater  or  less  severity  is  the  result. 

Under  these  conditions  the  muscles  sometimes  suffer,  while 
the  ligaments  escape.  The  injury  may  be  immediate,  or  not 
show  itself  until  some  time  has  elapsed  They  may  be  torn  or 
bruised  by  the  violence  with  which  the  bones  are  wrenched 
apart;  or  what  is,  perhaps,  more  common,  hurt  themselves 
by  the  sudden  and  almost  involuntary  attempt  at  recovery 
when  a  slip  is  threatened.  If  they  escape  at  the  moment  they 
may  suffer  even  more  seriously  at  a  later  period  from  wasting, 
rigidity,  or  degeneration,  so  that  in  severe  cases  they  become 
converted  into  dense  unyielding  bands.  This,  perhaps,  is  not 
a  common  occurrence  when  recovery  is  rapid,  though  it  is  by 
no  means  unknown;  when  it  is  delayed,  they  rarely  fail  to 
show  that  they  have  undergone  some  kind  of  change,  and  that 
they  are  not  so  perfect  as  they  were  before. 

The  Effects  of  Muscular  Development. — Besides,  however, 
acting  as  a  safeguard  and  protection  against  accidents  of  this 
nature,  the  muscular  system  is  of  great  importance  in  another 
•way.  The  degree  of  perfection  to  which  joints  attain — and 
naturally  they  differ  immensely  in  this  respect  in  different  in- 
dividuals— is  dependent  entirely  on  the  extent  to  which  the 
muscular  system  is  developed. 

Where  the  muscles  are  poor  and  feeble  the  joints  are  poor 
and  feeble  too,  and  are  easily  sprained.  The  ends  of  the  bones, 
instead  of  being  angular,  with  sharply-cut  and  well-defined 


22  Sprains ;  their  Consequences  and  Treatment. 

edges,  are  smooth  and  rounded.  The  articular  surfaces  are 
faintly  marked,  so  that  they  can  glide  on  each  other  in  irregu- 
lar and  unusual  directions;  the  capsule  is  loose  and  yielding, 
and  the  ligaments,  without  the  assistance  of  the  muscles,  are 
unable  to  withstand  the  least  strain,  or  even  to  maintain  the 
normal  relation  of  the  two  bones.  The  action  of  the  joint  is 
uncertain  and  often  painful,  and  the  loss  of  power  is  propor- 
tionate. In  case  of  anj  extra  work  the  bony  surfaces  glide 
irregularly  on  each  other,  and  move  beyond  their  ordinary 
limit.  The  more  often  this  takes  place  the  more  easy  it  is  for 
it  to  happen  again.  Each  time  it  is  always  carried  a  little 
farther  than  it  was  before,  until  at  length,  some  day,  one  bony 
prominence  is  caught  behind  another  over  which  it  has  slipped, 
or  a  tendon  or  disc  of  cartilage  escapes  from  its  bed,  and  the 
joint  is  locked.  Pain  and  swelling  rapidly  follow.  The  patient 
may  be  able  to  restore  things  to  their  natural  position  at  the 
first,  but  more  often  some  assistance  is  required.  The  serious 
thing  is  that  when  this  occurs,  as  it  is  wont  to  do  more  and 
more  often,  the  joint  never  has  time  to  recover  its  natural 
condition,  and  is  left  permanently  damaged. 

The  principle  that  the  more  a  part  is  used,  within,  of  course, 
rational  limits,  the  more  perfect  it  becomes,  has  long  been 
recognized  in  the  case  of  bones.  The  skeleton  of  the  male  is 
very  different  from  that  of  the  female ;  the  work  is  harder,  and 
the  bones  become  stronger.  In  the  one  they  are  solid,  heavy, 
and  exceedingly  irregular,  from  the  development  of  muscular 
ridges;  in  the  other  they  are  lighter  altogether,  and  much 
more  smooth  and  even.  So  with  animals  that  have  long  been 
kept  in  confinement,  the  bones,  contrasted  with  those  of  wild 
ones  of  the  same  species,  scarcely  admit  of  comparison,  the 
difference  is  so  great.  It  is  the  same  with  the  muscles.  As 
Humphry  has  pointed  out,  there  is  a  difference  almost  of  kind 
between  the  slender,  compact  frame  and  wiry,  active  muscular 
system  of  the  thoroughbred,  and  the  coarser,  heavier,  and 
more  clumsy  tissues  of  the  cart-horse. 

What  is  true  of  the  shafts  and  muscular  eminences  of 
bones  is  equally  true  of  their  articular  ends,  and  of  the  rough 
surfaces  to  which  ligaments  are  attached.  Joints  are  well 
formed  and  secure  from  injury,  so  far  as  shape  can  make  them, 
in  proportion  to  the  amount  of  their  use  and  the  perfection  of 
the  muscular  system. 


Sprains ;  their  Consequences  and  Treatment.  23 

Chronic  Sprains. — Such  a  condition  as  the  one  I  have  de- 
scribed above  may  be  almost  called  a  state  of  chronic  sprain. 
So  long-  as  it  is  slight  it  does  not  attract  much  attention. 
There  are  complaints  of  loss  of  power,  and  of  twisting-  or  giv- 
ing- way,  but,  as  a  rule,  the  deformity  is  not  conspicuous,  and 
especially  as  it  is  most  common  in  children,  it  is  put  down  to 
what  is  called  growing-  pain,  a  name  which  has  probably  done 
as  much  harm  as  any  other  by  the  way  in  which  it  makes 
ligiit  of  what  often  is  the  commencement  of  a  serious  disease. 
When  it  is  more  severe,  or  when  during-  some  unaccustomed 
effort  the  limb  fails  completely,  the  joint  is  generally  said  to 
be  out.  The  pain  is  very  severe;  swelling-  soon  makes  its  ap- 
pearance, owing-  partly  to  the  unnatural  position  of  the  bones, 
partly  to  the  effusion  round ;  and,  owing-  to  the  insecurity  of 
the  joint,  the  loss  of  power  is  so  great  that  the  patient  often 
believes  himself  paralyzed.  It  is  serious,  not  on  account  of 
the  tearing-  of  the  capsule  or  the  injury  to  the  parts  around, 
but  because  the  cause  is  such  a  persistent  one,  because  the 
condition  of  thing's  which  has  given  rise  to  it  is  one  that  re- 
quires a  long-  and  systematic  course  of  treatment  before  it  can 
be  rectified. 

One  of  the  earliest  and  most  characteristic  examples  I  have 
seen  was  in  a  young-  girl  who  was  broug-ht  to  me  complaining 
of  partial  paralysis  of  the  rig-ht  arm,  attended  at  times  with 
attacks  of  severe  pain.  She  was  a  tall,  overgrown  girl  four- 
teen years  of  ag-e,  employed  as  a  nursemaid,  having-  to  carry 
about  a  heavy  child,  and  owing-  to  this  condition  of  her  arm, 
which  had  been  coming-  on  grad  ually  for  the  last  three  or  four 
months,  had  lost  her  situation.  She  was  not  aware  of  having 
sustained  any  single  severe  injury  to  her  shoulder;  but  stated, 
of  her  own  accord,  that  long  before  it  reached  its  present  state 
it  was  continually  giving  way,  or,  as  she  expressed  it,  coming 
out  of  joint.  On  comparing  the  two  sides  together,  it  was  evi- 
dent that  the  muscles  round  the  shoulder  joint  on  the  affected 
side  were  smaller  than  those  on  the  other,  though  the  differ- 
ence was  not  equally  marked  in  all.  The  movements  were 
limited  to  a  great  extent  by  the  pain  they  occasioned,  and  the 
general  muscular  strength  was  decidedly  below  normal.  The 
cause  was  apparent  at  once;  there  was  a  large  amount  of 
thickening  over  the  point  of  the  shoulder  round  the  joint,  that 
is  to  say,  between  the  collar-bone  and  the  shoulder-blade;  and 


24  Sprains ;  their  Consequences  and  Treatment, 

the  bones  were  so  loosely  connected  together  that  the  end  of 
one  could  easily  be  made  to  slip  backward  and  forward  over 
the  end  of  the  other.  When  the  shoulder-blade  was  held  in 
position  by  firm  pressure  from  behind,  the  movements  of  the 
arm  could  be  executed  nearly  as  well  as  those  of  the  opposite 
limb,  and  with  nearly  as  much  vigor,  while  the  wasting1  dimin- 
ished so  much  that  evidently  it  was  in  the  main  apparent  only. 
As  soon  as  the  pressure  was  taken  off,  the  bone  at  once  under- 
went considerable  rotation,  the  upper  border  being1  so  much 
displaced  that  a  deep  hollow  made  its  appearance  behind  the 
collar-bone,  which  slid  in  such  a  direction  that  the  two  com- 
pletely lost  their  normal  relation  to  each  other. 

The  fact  that  the  wasting  almost  disappeared,  and  that 
the  movements  could  be  executed  with  ease  as  soon  as  the 
shoulder-blade  was  fixed,  quite  negatived  the  idea  of  paralysis. 
The  slight  amount  of  real  wasting,  affecting  only  a  few  of  the 
muscles,  could  easily  be  accounted  for  by  the  inflammation  of 
and  round  the  joint;  wasting  much  more  extensive  than  this 
sometimes  under  these  circumstances  comes  on  within  a  week. 
There  was  no  history  of  any  accident  sufficiently  severe  to 
suggest  the  idea  of  a  dislocation  with  rupture  of  the  liga- 
ments; the  onset  of  the  mischief  had  been  quite  slow  and 
gradual,  though  every  now  and  then  the  pain — which  had,  as 
usual,  been  called  growing  pain — and  the  inconvenience  had 
suddenly  become  worse.  For  the  same  reason  it  could  hardly 
be  termed  a  partial  dislocation ;  the  capsule  was  not  torn,  and 
the  whole  thing  had  come  on  slowly  and  imperceptibly,  so  that 
the  patient  could  assign  no  date  at  all  for  its  first  commence- 
ment. The  characteristic  features  were  the  weak  muscular 
development,  the  imperfection  in  the  shape  of  the  articular 
ends,  and  the  loose  yielding  condition  of  the  ligaments.  So 
long  as  no  extra  strain  fell  on  the  joint,  the  muscles,  weak  and 
feeble  as  they  were,  were  sufficient  to  maintain  the  surfaces  in 
contact;  a  little  extra  work,  slowly  and  gradually  in  this  case, 
tiring  out  the  muscles,  allowed  the  strain  to  fall  on  the  liga- 
ments, until,  as  ligaments  always  will  when  subjected  to  long- 
continued  tension,  they  gradually  stretched  more  and  more, 
and  became  so  loose  that  the  end  of  one  bone  could  slip  back- 
ward and  forward  and  ride  over  that  of  the  other. 

A  similar  case,  differing,  however,  in  the  joint  affected,  that 
between  the  collar-bone  and  the  breast-bone,  and  in  the  fact 


Sprains ;   their  Consequences  and  Treatment.  25 

that  it  was  distinctly  made  worse  by  one  rather  severe  strain, 
came  under  my  notice  almost  the  same  day.  The  patient, 
who  was  also  a  girl,  aged  about  18  years,  had  suddenly  felt  a 
severe  pain  in  this  joint  two  days  before  as  she  was  trying1  to 
lift  a  heavy  weight,  and,  of  course,  had  been  told  the  joint 
"  was  out."  At  the  first  glance  this  did  not  seem  unlikely,  for 
the  inner  extremity  of  the  collar-bone  was  much  too  prominent ; 
but  there  was  very  little  swelling  or  tenderness,  and  no  bruis- 
ing whatever.  On  further  inquiry,  too,  it  was  elicited  from 
the  patient  that  for  some  months  past  the  arm  had  felt  very 
weak  and  unsteady  in  its  movements.  Examination  of  the 
opposite  joint  showed  that  it  was  nearly  in  the  same  condi- 
tion, and,  in  fact,  the  bones  on  both  sides  were  so  loose  that 
they  could  be  pushed  almost  as  far  backward  and  forward 
as  they  could  upward.  Clearly,  the  ligaments  were  unusually 
lax,  and  two  days  before,  when  an  unaccustomed  strain  fell  on 
the  right  joint,  it  gave  way,  causing  so  much  pain  and  incon- 
venience that  the  patient  was  compelled  to  seek  advice. 

These  two  cases  are,  perhaps,  somewhat  exaggerated  ex- 
amples, because  in  both  the  already  loose  condition  of  the  liga- 
ments had  been  intensified  by  severe  strains;  the  same  state, 
however,  exists  independently  of  these,  and  no  joint  in  the 
body  is  exempt.  The  shoulder,  as  might  be  imagined  from 
the  description  already  given,  is  peculiarly  prone  to  suffer. 
If  the  joint  is  poorly  developed,  or  the  muscles  on  which  it 
depends  for  its  security  are  lax  and  feeble,  it  can  readily  be 
made  to  assume  abnormal  positions.  Sometimes  this  occurs 
with  any  movement,  more  often  only  with  certain  definite 
actions;  in  one  cas  ,  a  girl  of  16,  whom  I  watched  for  a  long 
time,  whenever  in  dressing  of  a  morning  she  placed  her  hand 
on  the  back  of  her  head  in  trying  to  arrange  her  hair,  the 
upper  end  of  the  humerus  slipped  over  the  edge  of  its  socket, 
and  was  caught  there.  At  length  she  learned  by  a  clever 
twisting  action  to  bring  it  into  its  place  again,  and  even  grad- 
ually to  avoid  displacing  it  altogether. 

In  the  elbow  joint,  from  the  shape  of  the  bones,  this  acci- 
dent can  scarcely  happen;  but  the  same  condition  of  things 
occurs.  Examples  may  often  be  met  with  in  which  the  fore- 
arm can,  without  any  violence  or  pain,  be  bent  back  to  an  ab- 
normal extent  on  the  arm;  the  ligaments  in  front  are  so  loose 
that  they  do  not  check  the  movement  sufficiently,  and  the 


26  Sprains ;  their  Consequences  and  Treatment. 

bones  so  feebly  developed  that  their  projecting  extremities  do 
not  come  into  contact  with  each  other  until  the  normal  range 
is  greatly  exceeded. 

In  the  case  of  the  lower  jaw  it  has  long  been  known. 
Hamilton  described  it  as  occurring  in  his  own  person,  and, 
naturally,  with  the  greatest  possible  accuracy.  He  has  no- 
ticed, also,  the  curious  circumstance  that  this  displacement, 
when  it  does  occur,  is  much  more  common  in  the  morning  than 
at  any  other  time  of  day.  Particularly  at  breakfast  the  lower 
jaw,  owing  to  the  looseness  of  the  ligaments  that  should  re- 
strict its  action,  is  apt  to  become  locked  when  the  mouth  is 
opened  at  all  widely,  and  some  manipulation  is  required  to 
bring  it  back  again. 

Whether  the  same  thing  can  occur  in  connection  with  the 
hip  is,  I  should  think,  very  doubtful.  I  have  seen  one  patient 
who  could  at  will  dislocate  her  thigh-bone  by  a  peculiar  twist- 
ing of  the  limb;  but  in  the  absence  of  any  history  that  could 
be  relied  on,  and  as  her  other  joints  gave  no  sign,  which  they 
almost  certainly  would  have  done  in  such  an  extreme  case,  I 
should  imagine  that  probably  this  condition  had  existed  from 
birth,  by  virtue  of  some  congenital  defect.  In  the  knee  minor 
degrees  of  it  are  quite  common,  not  only  allowing  abnormal 
movements  of  the  leg  upon  the  thigh,  but  also  giving  too  wide 
a  range  of  action  to  the  semi-lunar  cartilages  in  the  interior 
of  the  joint,  whereby,  perhaps,  at  length  is  brought  about  the 
beginning  of  a  most  serious  affection  known  as  internal  de- 
rangement. 

It  is  singular  that  this  condition  of  the  joints,  which  is  very 
common  in  slighter  degrees,  and  very  striking  in  the  exag- 
gerated form  I  have  described  above,  should  have  attracted 
so  little  attention.  Sir  Astley  Cooper  has  described  it  in  the 
case  of  one  joint.  Hamilton  mentions  it  from  his  own  personal 
experience  in  another.  Malgaigne  gives  a  vague  account  of 
something  similar,  but  although  he  regards  it,  quite  correctly, 
as  the  consequence  of  debility,  and  often  determined  to  one 
particular  joint  by  a  local  trouble,  such  as  a  sprain,  he  does 
not  appear  to  recognize  it  as  a  general  condition,  affecting 
many  joints  at  one  and  the  same  time;  and  he  fails  altogether 
to  separate  it  from  cases  in  which  the  capsule  or  ligament 
have  been  weakened,  or  stretched  by  inflammation,  or  by  the 
passive  accumulation  of  fluid  in  their  interior.  It  is  even  more 


Sprains;  their  Consequences  and  Treatment.  27 

strange  that  he  fails  to  appreciate  the  fact  that  the  ligaments, 
though  undoubtedly  concerned  in  the  production  of  this  condi- 
tion, are  in  reality  only  passive  agents,  and  not  in  any  way 
the  immediate  cause.  He  states  that  it  is  due  to  an  essential 
relaxation  of  the  ligaments,  though  he  fails  to  describe  what 
this  may  be.  In  reality  it  is  the  muscular  system  that  is  at 
fault;  for  on  this  more  than  anything  else  depends  the  perfec- 
tion of  the  joints,  and  the  strength  and  power  of  resistance  of 
the  ligaments. 

The  secret  of  it  all  is  to  be  found  in  the  feebleness  of  the 
muscular  system.  In  the  first  place  the  joints  are  weak,  and 
the  ligaments  loose,  because  they  have  not  been  properly  ex- 
ercised. Then  the  muscles  are  not  equal  to  any  amount  of 
work.  When  a  little  extra  labor  falls  on  them  (and  very  little 
is  needed  in  cases  such  as  these)  they  soon  become  fatigued; 
the  joints  lose  their  support,  and  either  the  already  feeble  liga- 
ments yield  slowly  and  steadily,  with  a  very  considerable 
amount  of  pain,  as  ligaments  always  will  yield  when  exposed 
to  any  severe  strain;  or  else,  owing  to  some  sudden  slip,  the 
weight  of  the  body  falls  on  them  before  the  muscles  can  save 
them,  and  some  permanent  injury  is  the  result.  It  cannot  be 
too  clearly  laid  down  that  not  only  do  the  joints  depend  for 
their  perfection  on  the  degree  of  development  of  the  muscles, 
but  that,  at  any  moment,  the  contraction  of  the  muscles  round 
a  joint  is  as  essential  to  its  security  as  the  ligaments,  perhaps 
more  so.  If  they  yield,  the  ligaments  will  never  hold  for  long. 

Effects  of  Age  on  Joints. — One  other  feature  in  the  con- 
struction of  joints  cannot  be  passed  over  in  silence,  as  it  helps 
to  explain  why  sprains  in  some  people  are  so  liable  to  be  fol- 
lowed by  complications  from  which  others  are  quite  exempt. 
The  joints  are  not  alike  at  &ny  two  periods  of  life.  It  is  ac- 
knowledged that  they  do  not  attain  their  highest  stage  of  per- 
fection until  adult  years  are  reached,  but  even  after  this  their 
most  important  features  undergo  continual  modifications.  In 
infancy,  adult  life,  and  old  age  there  are  vast  degrees  of  differ- 
ence in  their  structure,  due  partly  to  the  way  in  which  they 
have  been  used,  partly  to  the  natural  changes  that  take  place 
in  them  as  age  advances,  and  partly  to  disease. 

Leaving  aside  for  the  present  this  last  consideration,  the 
differences  that  exist  between  the  joints  at  various  periods  of 
life  are  most  striking.  In  the  infant  the  surfaces  and  edges 


28  Sprains ;  their  Consequences  and  Treatment. 

of  the  cartilages  are  rounded  and  smooth,  closely  fitting1  to- 
g-ether at  the  centre  so  as  to  leave  between  them  merely  a 
cleft,  which  widens  a  little,  but  very  little,  at  the  margin.  The 
shape  of  the  joint  cavity  is  well  defined,  regular,  and  even. 
There  are  no  outlying  pouches  or  projecting  fringes;  every- 
thing is  as  simple  as  it  can  be.  The  fibrous  capsule  round 
presents-  the  same  features.  It  is,  it  is  true,  a  little  stronger 
in  one  part  than  it  is  in  another,  but  there  are  no  great  acces- 
sory bands  of  dense  unyielding  ligament.  All  is  soft  and  deli- 
cate in  structure,  shading  off  imperceptibly  into  the  surround- 
ing connective  tissue,  and  what  is,  perhaps,  the  most  important 
feature  of  all,  exceedingly  richly  supplied  with  blood-vessels. 
In  the  adult  these  are  confined  almost  entirely  to  two  circles 
which  surround  the  ends  of  the  bones,  where  the  capsule  is 
attached,  and  send  loops  into  the  folds  and  fringes  which 
abound  there.  In  the  child,  and  still  more  in  the  infant,  not 
only  are  they  larger  and  more  numerous  in  proportion  to  the 
size  of  the  parts,  but  they  extend  over  the  whole  circumference, 
and  are  not  limited  to  any  single  region.  In  consequence  of 
this,  when  inflammation  arises,  no  matter  what  may  be  the 
cause,  its  course  is  much  more  rapid,  and  the  exudation  of 
lymph  infinitely  more  profuse.  In  children  sprains  are  at- 
tended by  an  altogether  disproportionate  amount  of  swelling, 
and  probably  many  of  the  complications  that  occur  in  them 
are  due,  not  so  much  to  inherited  tendency  as  to  the  extraor- 
dinary richness  of  the  blood  supply,  and  the  rapid  and  tumult- 
uous character  of  the  tissue  changes  that  take  place  under 
such  conditions. 

All  through  life,  not  merely  in  youth,  but  even  in  old  age, 
this  undergoes  continual  change.  The  difference  is  not  only 
one  of  size,  but  of  structure,  arrangement,  and  relation.  The 
cartilage  is  replaced  by  bone,  with  the  exception,  as  already 
mentioned,  of  the  layer  that  directly  lines  the  cavity.  The 
edges  become  sharp  and  well  defined,  and  the  surfaces  are  no 
longer  moulded  accurately  to  each  other.  The  capsule  in- 
creases in  strength  and  thickness.  Where  the  strain  is  great 
the  delicate  connective  tissue  becomes  dense  and  unyiel cling 
ligament;  in  other  places  it  forms  a  close  and  even  membrane 
round  the  central  space.  But  these  alterations,  great  as  they 
are,  are  slight  when  compared  with  those  of  the  synovial  cav- 
ity and  its  delicate  lining.  This  not  only  increases  in  size  in 


Sprains ;  their  Consequences  and  Treatment.  29 

proportion  to  the  growth  of  the  joint,  but  becomes  greatly 
changed  in  shape.  Pouches  are  thrown  out  round  the  bony 
projections  and  into  the  weaker  parts  of  the  capsule  until  in 
outline  it  bears  scarcely  any  resemblance  to  what  it  was  at 
birth.  Accessory  spaces,  known  as  bursse,  are  developed 
wherever  there  is  friction,  under  tendons,  for  example,  or  be- 
tween bones  and  muscles.  These  differ  in  each  individual  both 
as  regards  shape  and  position.  As  age  advances  the}-  become 
larger  and  larger,  until  at  length  they  encroach  to  such  an 
extent  on  the  lining  membrane  of  the  joint  cavity  that  the 
intervening  partition  gives  way,  and  a  communication  be- 
tween them  is  established  by  an  opening  which  grows  wider 
and  wider  each  year. 

While  this  is  going  on  the  surface  of  the  lining  membrane 
does  not  lag  behind.  It  does  not  remain  smooth  and  regular, 
merely  folded  on  itself  where  it  is  reflected  on  the  bones.  Pro- 
jections grow  into  the  cavity  from  all  sides.  Some  spring  up 
from  the  spot  where  the  capsule  is  attached  to  the  bones,  so 
that  these  are  surrounded  by  a  ring  of  fringing  growths. 
Others  project  inward  from  the  ridges  and  inequalities  of  the 
surface  or  the  margins  of  the  openings  already  mentioned. 
Some  are  short  and  smooth,  others  long  and  branched.  In 
some  the  end  expands  into  a  rounded  body  containing  carti- 
lage corpuscles,  while  the  neck  grows  thinner  and  thinner 
until  it  gives  way  and  allows  it  to  drop  off.  Many  of  them 
contain  loops  of  vessels,  especial^  when  they  grow  from  the 
region  of  the  vascular  circles;  other  are  merely  masses  of 
fibrous  tissue.  There  may  be  only  a  few  scattered  about,  or 
the  whole  interior,  especially  if  examined  under  water,  may 
be  covered  with  a  dense  shaggy  coating  under  which  it  is  no 
longer  possible  to  recognize  the  polished  regular  surface  met 
with  in  youth  and  childhood. 

It  is  often  difficult  to  .tell  how  far  these  changes  are  the 
result  of  age,  or  to  what  extent  they  are  the  direct  consequences 
of  disease;  the  two  so  often  go  together  hand  in  hand.  The 
effect  is  that  in  no  two  persons  are  the  joints  ever  alike;  and 
the  older  thej7  become,  the  more  work  and  the  harder  the 
work  they  are  called  upon  to  do,  the  greater  the  changes  and 
the  wider  the  difference,  until  at  length  it  is  scarcely  possible 
to  find  a  resemblance  except  in  the  broad  general  features  of 
construction. 


OHAPTEE  III. 

DIAGNOSIS. 

IT  is  not  often  that  there  is  much  difficulty  in  the  diagnosis 
of  a  sprain,  particularly  if  the  joint  is  a  superficial  one,  like 
the  ankle  or  the  knee.  The  nature  of  the  accident,  the  sudden 
onset  and  peculiar  character  of  the  pain,  the  rapid  swelling-  of 
the  part,  and  the  helplessness  of  the  limh,  are  in  general  quite 
sufficient  to  convince  the  patient  of  the  misfortune  that  has 
befallen  him.  But  as,  short  of  actual  dislocation,  nearly  every 
kind  of  injury  that  can  involve  either  a  joint  or  the  tissues  in 
its  immediate  neighborhood,  is  called  a  sprain,  this  is  scarcely 
sufficiently  definite.  In  no  other  kind  of  accident  do  precision 
and  exactness  of  diagnosis  repay  more  thoroughly  the  pain 
and  trouble  of  careful  examination;  nowhere  is  it  more  essen- 
tial to  form  a  definite  conclusion  as  early  as  possible,  not  only 
of  the  kind  of  hurt  sustained,  but  of  its  extent  and  degree. 
Even  then  it  often  happens  that  constitutional  peculiarities, 
or  other  agencies  less  easily  controlled,  assert  their  influence, 
and  seriously  complicate  the  progress  of  the  case. 

Dislocations,  fractures  in  the  neighborhood  of  joints,  and, 
in  the  case  of  children,  separation  of  one  of  the  growing  ends 
of  the  bones,  present  the  greatest  amount  of  difficulty.  In 
connection  with  this,  there  are  one  or  two  points  which  it  is 
advisable  to  bear  in  mind.  In  the  first  place,  in  many  joints, 
and  particularly  in  those  in  which,  like  the  elbow,  complicated 
accidents  are  of  common  occurrence,  an  enormous  amount  of 
swelling  sets  in  with  such  rapidity  that  all  the  prominences 
by  which  the  relative  position  of  the  bones  is  ascertained  are 
buried  and  lost  in  a  very  short  time.  Consequently,  if  the 
diagnosis  is  not  made  at  once,  immediately  after  the  accident, 
it  is  necessary  either  to  put  the  patient  under  an  anaesthetic 
or  to  wait  without  a  definite  opinion  for  days,  perhaps  even 
for  weeks,  until  the  swelling  subsides.  The  importance  of  this 
is  so  great  that,  especially  at  the  present  day,  there  ought  to 


Sprains ;  their  Consequences  and  Treatment.  31 

be  no  hesitation  about  the  administration  of  an  anaesthetic. 
In  the  case  of  children,  it  is  often  impossible  to  form  an  opinion 
without ;  and  even  when  it  is,  the  risk  is  so  exceedingiy  slight, 
the  relief  from  pain  so  great,  and  the  advantages  of  being-  able 
to  examine  the  joint  thoroughly  without  any  muscular  rigid- 
ity, and  to  apply  the  first  dressings  quietly  and  systematically, 
so  immense,  that  they  ought  to  be  made  use  of  where  there  is 
the  least  occasion.  Nothing  is  more  common  than  to  meet 
with  cases  in  which,  from  neglect  of  this  precaution,  because 
the  first  examination  could  not  be  thorough,  joints  have  re- 
mained stiff  or  imperfect  in  their  action  throughout  the  greater 
part  of  life. 

Further,  if  there  is  the  slightest  question  as  to  the  nature 
of  the  injury,  whether  it  is  a  fracture  involving  a  joint,  or  a 
sprain,  the  patient  must  always  be  given  the  benefit  of  the 
doubt,  and  the  injury  treated  as  if  it  were  the  more  serious  of 
the  two,  with  this  precaution,  that  passive  motion  must  be  re- 
sorted to,  and  the  joint  thoroughly  worked  at  a  much  earlier 
period  than  it  would  be  in  the  case  of  a  simple  uncomplicated 
fracture.  It  is  probable  that  sprains  of  the  ankle  are  very 
frequently  confused  with  fractures  of  the  small  bone  of  the 
leg,  and  even  with  Pott's  fracture  without  displacement  of  the 
parts;  but  as  the  immediate  method  of  treatment  adopted  in 
these  instances  need  not  differ  materially,  no  ill  result  follows, 
provided  passive  motion  is  adopted  in  time.  Stiff  joints, 
whether  they  are  the  result  of  fractures  or  of  sprains,  result 
most  often  from  retaining  the  part  immovable  in  a  fixed  ap- 
paratus for  weeks  together. 

There  is  one  further  caution  which  it  is  necessary  to  ob- 
serve, one  that  was  originally  suggested  by  Nelaton.  It  some- 
times happens  that,  even  when  only  a  single  joint  is  complained 
of,  one  or  more  of  the  others  in  the  same  limb  has  sustained 
some  hurt,  though  of  less  severity.  Consequently  it  is  as  well, 
when  examining  a  sprained  limb,  always  to  commence  by  in- 
vestigating the  movements  of  the  joints  which  the  patient 
declares  not  to  have  been  hurt ;  otherwise  they  may  easily  be 
overlooked,  and  some  time  later  an  aggravating  degree  of 
stiffness  found  that  might  easily  have  been  avoided  by  the  ex- 
ercise of  a  little  precaution.  There  is  this  further  advantage, 
though  it  may  not  be  worth  much,  that  the  patient,  when  the 
joint  that  really  has  been  injured  is  taken  in  hand,  knows 


32  Sprains ;   their  Consequences  and  Treatment. 

what  is  going-  to  be  done,  and  is  less  apprehensive  of  any 
rough  movement. 

The  same  thing  may  happen  when  one  of  the  bones  is 
broken:  a  sprain  and  a  fracture  may  occur  in  the  same  limb 
from  the  same  accident,  and  owing  to  the  great  amount  of 
attention  paid  to  the  one,  the  other  may  be  altogether  over- 
looked. Dr.  Bennett,  of  Dublin,  narrates  the  case  of  a  man 
who  slipped  as  he  was  carrying  a  heavy  sack  down  a  sloping 
plank.  His  foot  was  suddenly  checked  in  its  slide  by  some 
irregularity,  and  he  fell,  conscious  at  the  time  that  something 
had  given  way  in  his  leg.  Admitted  into  hospital,  as  he  was 
unable  to  bear  any  weight  on  his  limb,  he  presented  the  or 
dinary  features  of  sprained  ankle,  without  any  sign  of  fract- 
ure. The  case  was  treated  as  a  severe  sprain,  and  attracted 
but  little  attention  for  some  days,  until  it  was  noticed  that 
there  were  some  signs  of  bruising  on  the  upper  part  of  the  leg. 
On  examination,  the  localized  pain,  and  the  crepitus  character- 
istic of  fracture,  left  no  room  for  doubt  as  to  the  diagnosis. 
In  addition  to  his  sprain,  the  small  bone  of  the  leg  had  given 
way  a  long  distance  from  the  ankle,  though  he  was  certain  he 
had  not  struck  it  in  his  fall.  The  amount  of  displacement  of 
the  broken  ends  was  very  slight;  the  line  of  fracture  was 
oblique;  and  there  is  no  doubt  it  might  easily  have  been  passed 
over  altogether.  Probably,  as  Dr.  Bennett  suggests,  accidents 
of  this  kind  are  much  more  common  than  is  usually  supposed. 

Swelling. — Much  of  the  difficulty  of  diagnosis  arises  from 
the  variety  of  the  symptoms  presented  by  sprains;  they  are 
scarcely  alike  in  any  two  cases.  In  hinge  joints,  for  example, 
the  mischief  falls  on  the  ligaments  which  oppose  a  twisting 
force;  in  a  ball  and  socket  arrangement,  the  muscles,  as  a 
rule,  are  the  greatest  sufferers.  Sometimes,  especially  when 
it  is  due  to  haemorrhage,  the  swelling  makes  its  appearance  at 
once,  and  accurately  reproduces  the  shape  of  the  synovial  sac. 
At  others  the  bursaB  or  the  tendon  sheaths  in  the  neighbor- 
hood are  distended,  so  that  this  is  quite  concealed,  or  there 
are  extensive  extravasations  into  the  loose  cellular  spaces  un- 
derneath the  skin  and  between  the  muscles.  Or,  again,  the 
swelling  may  commence  slowly  and  gradually,  twelve,  or  even 
twenty-four  hours  after  the  injury,  and  be  smooth  and  uni- 
form in  outline  from  the  very  first,  owing  to  the  effusion  into 
the  soft  tissue  round  as  well  as  into  the  joint  itself. 


Sprains ;  their  Consequences  and  Treatment.  33 

Very  often  it  is  most  distinct  over  the  course  of  the  mus- 
cles and  tendons.  The  skin,  for  example,  on  the  outer  side  of 
the  forearm  is  raised  and  puffy  over  the  insertion  of  the  pro- 
nator  radii  teres,  or  there  is  a  long1,  low,  rounded  swelling-  on 
the  back  of  the  wrist,  running-  obliquely  across  the  joint  over 
the  course  of  the  extensor  muscles  of  the  thumb.  It  is  quite 
soft — so  soft,  indeed,  that  it  can  often  be  appreciated  better 
by  the  eye  than  by  the  finger — never  very  great,  because  there 
is  no  cavity  of  any  size  in  which  fluid  can  collect,  but  exceed- 
ingly tender  when  touched. 

Sometimes,  instead  of  the  bony  prominences  being-  partly 
buried  by  the  collection  of  lymph  round  and  between  them, 
the  reverse  of  this  is  the  case.  They  are  increased  in  size,  and 
stand  out  under  the  skin  in  such  a  way  that  there  may  be 
some  apparent  ground  for  the  common  conclusion  that  the 
joint  is  out.  In  the  wrist  and  hand  this  is  a  very  frequent 
mistake,  and  it  really  is  difficult  sometimes,  when  one  of  these 
points  is  projecting  beneath  the  skin,  to  prove  that  the  bone 
has  not  slipped  out  of  its  place  and  been  dislocated. 

The  styloid  process  of  the  ulna  on  the  inner  side  of  the 
wrist  is  a  favorite  spot  for  this.  It  is  often  unduly  prominent 
after  an  attack  of  gout  or  rheumatism,  and,  even  when  it  is 
certain  there  has  been  no  injury,  it  is  frequently  described  as 
being-  out.  So  with  the  base  of  the  metacarpal  bone  of  the 
middle  finger,  which,  when  the  wrist  is  strongly  bent,  raises 
up  the  skin  on  the  back  joint.  This  often  forms  a  projection, 
especially  in  gouty  people,  varying1  in  size  from  time  to  time, 
and  occasionally  appears  quite  suddenly  after  even  slight  ex- 
ertion. Probably  it  is  due  to  a  strain  of  the  tendon  attached 
to  this  point,  and  to  the  amount  of  effusion  thrown  out  round 
the  bone,  but  it  is  nearly  always  asserted  that  something  is 
out  of  joint. 

Other  parts  of  the  body  are  not  so  liable  to  mistakes  of 
this  kind,  in  all  probability  because  they  are  not  exposed  to 
such  continual  and  minute  examination.  In  the  knee  and 
elbow,  even,  considerable  differences  are  not  noticed  unless 
they  have  appeared  suddenly.  Natural  projections  may  in- 
crease in  size,  fresh  ones  may  form,  or  what  is  perhaps  more 
perplexing  still,  small  ganglions  may  develop  in  such  places 
as  the  outer  side  of  the  knee  joint,  just  below  the  level  of  the 
knee  cap,  and  at  the  same  time  there  may  be  real  impairment 


34  Sprains ;  their  Consequences  and  Treatment. 

of  mobility  and  strength,  but  unless  this  happens  suddenly, 
or,  what  is  far  more  common,  is  noticed  suddenly,  little  atten- 
tion is  paid  to  it.  When  there  has  been  a  recent  accident  the 
diagnosis  is  sometimes  very  difficult,  and  requires  the  greatest 
care. 

Staining. — Valuable  information  may  be  gained  sometimes 
from  the  place  at  which  the  bruising  first  shows  itself.  Blood 
effused  deep  down  in  a  limb,  as,  for  example,  between  the 
superficial  and  deep  muscles  of  the  calf  of  the  leg,"  or  in  the 
groin,  always  follows  certain  well-defined  routes,  being  guided 
by  the  anatomical  structure  and  the  arrangement  of  the  sheets 
of  fascia.  When  the  limb  is  bandaged  it  is  often  driven  great 
distances  by  the  pressure  before  it  can  reach  the  surface. 

Sometimes  its  distribution  is  very  peculiar.  I  have  seen 
several  instances  in  which,  after  a  severe  injury  to  the  deeper 
parts  of  the  hand,  dark  purple  crescents  caused  by  blood- 
staining  made  their  appearance  between  each  of  the  fingers, 
just  above  the  web  where  they  divide.  Owing  to  the  attach- 
ment of  the  palmar  fascia,  the  coloring  matter  had  soaked 
through  to  the  skin  in  a  regular  and  symmetrical  pattern. 

Pain. — The  character  of  the  pain,  if  the  patient  can  describe 
it,  may  be  of  great  help.  When  the  strain  falls  on  the  liga- 
ments it  is  usually  said  to  be  sickening,  and  a  patient  who  has 
suffered  from  it  once  rarely  fails  to  recognize  it  a  second  time. 
It  is  very  sudden,  often  so  severe  as  to  cause  the  sufferer  to 
faint,  and  then  gradually,  if  the  joint  is  kept  quiet,  passes  off 
again,  leaving  an  aching  deadness  of  the  limb,  but  coming 
back  in  an  aggravated  form  on  the  least  attempt  at  move- 
ment. This  is  well  marked  when  a  tendon,  or  one  of  the  in- 
ternal structures  of  a  joint,  slips  from  its  place.  So  long  as 
the  part  is  kept  perfectly  still,  even  if  the  position  is  abnormal, 
the  pain  is  only  moderate  in  severity;  it  becomes  worse  and 
worse  as  the  structure  shifts  from  side  to  side,  until  just  as  it 
slips  back  into  its  bed  it  is  as  severe  as  ever;  then  it  suddenly 
ceases.  The  cause  at  first  is  the  forcible  stretching  of  the 
ligaments;  the  later  aching  seems,  in  the  majority  of  instances, 
to  be  proportionate  to,  and  therefore  probably  dependent  on, 
the  amount  of  distention  of  the  joint. 

Tenderness. — Muscular  strains,  on  the  other  hand,  are  dis- 
tinguished by  a  peculiar  sensitiveness  of  skin,  most  marked 
over  the  points  of  attachment  to  the  bones  or  tendons.  These, 


Sprains;  their  Consequences  and  Treatment.  35 

as  a  rule,  are  the  weakest  spots,  where  they  give  way  first. 
If  they  are  even  touched  the  patient  shrinks  away  with  the 
pain ;  hut  curiously  enough,  very  often  steady,  gentle  pressure 
is  well  borne.  The  same  thing  happens  when  the  muscles  are 
overworked,  especially  during  convalescence.  At  this  time 
the  exertion  even  of  sitting  upright  is  sufficient,  because  the 
work,  trivial  though  it  is,  is  too  much  for  the  muscles  in  their 
weakened  state. 

When  a  muscle  is  torn  across,  either  wholly  or  partially, 
as  in  some  cases  of  lawn-tennis  leg,  the  symptoms  are  of  a 
totally  different  character.  There  is  a  sudden  sharp  pain,  like 
that  of  a  blow  with  a  whip  or  a  cricket  ball,  so  that  the  patient 
turns  round  to  see  who  has  struck  him,  before  he  is  aware  that 
anything  has  given  way;  and  then,  as  the  swelling  begins, 
this  is  followed  by  a  feeling  of  stiffness  and  soreness,  severe 
even  when  the  limb  is  at  rest,  but  so  much  worse  when  an  at- 
tempt is  made  to  use  it,  that  the  patient  often  can  hardly  be 
induced  to  try. 

Dislocation  of  a  muscle  is  not  unlike  this.  There  is  the 
same  sudden  pain,  and  the  part  is  held  fixed  in  the  position  of 
the  moment,  no  matter  how  inconvenient  it  may  be.  If,  for 
example,  one  of  the  muscular  slips  in  the  neck  is  displaced  by 
some  irregular  movement,  the  head  is  kept  rigid  in  the  posi- 
tion into  which  it  was  twisted.  It  is  not  possible  for  a  time 
to  bring  it  straight  again,  much  less  to  make  it  face  in  the 
opposite  direction ;  only  after  the  first  pain  has  subsided  can 
it  be  brought  round  by  slow  degrees.  Even  then,  as  soon  as 
the  attention  is  withdrawn,  it  quietly,  but  surely,  moves  back 
so  long  as  the  displacement  is  uncorrected.  When  the  parts 
are  restored  there  is  nothing  but  a  sensation  of  soreness,  writh 
a  tender  spot  or  line  in  the  neck  corresponding  to  the  particu- 
lar slip  displaced. 

These  tender  spots  often  afford  valuable  information.  They 
may  persist  long  after  apparent  recovery  has  taken  place,  and 
they  generally  point  to  something  which  is  not  quite  restored. 
In  a  sprained  ankle,  for  example,  if  one  of  the  lateral  ligaments 
has  given  way,  or  has  torn  off  a  scale  from  the  bone  to  which 
it  is  attached,  that  spot  remains  tender  for  weeks  after. 
Sometimes  they  indicate  the  presence  of  adhesions,  or  of  tough  , 
contracted  parts  of  the  capsule;  occasionally  they  correspond 
to  the  situation  of  synovial  fringes,  or  foreign  bodies,  or  to  the 


36  Sprains;  their  Consequences  and  Treatment. 

places  at  which  the  nerves  enter  the  joint;  and  in  one  or  two 
instances  I  have  known  them  caused  by  extravasation  in  the 
substance  of  the  capsule  itself. 

Allowance  must  be  made  for  those  that  are  normally  pres- 
ent when  a  joint  is  hurt.  What  they  are  caused  by  is  not 
always  certain,  but  as  a  rule  they  correspond  to  places  where 
the  capsule  is  thin  and  flexible,  and  not  far  removed  from  the 
surface,  so  that  pressure  falls  on  it  directly.  However  this 
may  be,  they  are  so  constant  and  definite  that  it  is  scarcely 
possible  to  mistake  them.  There  is  one,  for  example,  nearly 
always  present  on  the  inner  side  of  the  knee-cap,  about  the 
middle  of  the  joint;  in  the  hip  it  lies  behind  the  projection  of 
the  trochanter,  and  sometimes  there  is  one  also  on  the  inner 
side.  In  the  ankle  they  are  not  so  marked,  but  there  is  very 
generally  one  on  the  front  of  the  joint,  rather  to  the  outer  side 
of  the  middle  line.  These  are  present  with  such  regularity 
that  they  must  almost  be  called  normal.  When  other  more 
unusual  ones  are  found  there  is  some  additional  reason  to 
account  for  them. 

Sprains  and  Dislocations — the  Elbow  in  Children.— 
Sprains  and  dislocations  are  sometimes  very  confusing,  even 
without  taking1  into  consideration  the  popular  view  that  some- 
thing is  out  of  joint  in  every  sprain  that  does  not  get  well  at 
once.  One  instance  in  which  there  is  great  difficulty  in  dis- 
tinguishing them  has  been  mentioned  elsewhere,  and  it  would 
be  easy  to  multiply  them.  There  is,  for  example,  a  peculiar 
injury  about  the  elbow,  only  met  with  in  children,  concerning 
the  nature  of  which  there  is  still  very  considerable  doubt.  It 
is  caused  by  the  way  in  which  they  are  swung  round  by  the 
hands,  or  lifted  across  a  road;  and  is  rarely  seen  immediately, 
for  though  the  child  cries  out  with  the  pain,  there  is  no  dis- 
tinct or  objective  sign  of  anything  wrong.  Then  it  is  noticed 
that  the  arm  is  not  used  as  freely  as  the  other ;  that  the  child 
always  cries  when  it  is  touched ;  and  that  it  is  held  constantly 
in  one  position,  the  elbow  slightly  bent,  and  the  palm  of  the 
hand  looking  downwards.  Now,  certainly,  in  the  majority  of 
instances  the  seat  of  the  mischief  is  in  the  elbow  joint  (J. 
Hutchinson,  Jun.,  "Annals  of  Surgery,"  1885) ;  and  it  is  highly 
probable  that  it  is  due  to  one  of  the  bones  of  the  forearm,  on 
which  nearly  all  the  weight  falls,  slipping  out  from  under  the 
ligamentous  collar  which  holds  it  in  its  place.  But  this  view 


Sprains;  their  Consequences  and  Treatment.  37 

is  not  by  any  means  universally  held;  others,  describing"  the 
same  accident,  produced  in  the  same  way,  causing-  the  same 
symptoms,  and,  more  than  all,  cured  by  the  same  manipula- 
tion, have  assigned  it  to  a  totally  different  joint,  the  wrist. 

It  is  even  mistaken  for  fracture  sometimes,  for  a  very  sim- 
ple but  altogether  insufficient  reason.  If  the  elbow  is  held 
firmly  with  one  hand,  while  the  forearm  is  made  to  rotate 
slowly  from  side  to  side,  there  is  a  clicking-  or  snapping  sensa- 
tion, perceptible  both  to  the  ear  and  the  touch.  Then  some- 
thing- is  felt  to  slip,  and  in  g-eneral  free  use  of  the  joint  returns 
immediately.  But  sometimes  this  is  not  so  easy;  reduction 
does  not  take  place  at  once;  the  peculiar  sensation  continues, 
and  may  even  become  more  plain,  until  it  is  really  difficult  to 
distinguish  it  from  the  crepitus  of  fracture.  It  is  needless  to 
remark  that  whatever  may  be  the  actual  nature  of  the  hurt 
sustained,  it  can  scarcely  be  this.  If  the  displacement  is  recti- 
fied, and  the  arm  kept  quiet  for  a  day  or  two,  recovery  is 
nearly  always  complete  and  thorough,  which,  under  such  con- 
ditions, would,  of  course  be  quite  impossible. 

These  cases  are  of  everyday  occurrence;  though  there  may 
be  minute  points  of  difference,  they  resemble  each  other  in  all 
important  features;  the  anatomy  of  the  part  is  thoroughly 
well-known;  the  way  in  which  the  mischief  is  produced  can 
generally  be  ascertained;  and  there  is  nothing  mysterious,  or 
even  unusual,  in  the  manipulation  by  which  the  parts  are  re- 
stored. Yet  in  spite  of  all  this,  not  only  is  the  actual  nature 
of  the  injury  doubtful,  but  even  its  locality  is  uncertain.  When 
there  is  no  history  to  be  obtained,  or  only  one  that  is  confusing 
and  misleading,  and  when  the  limb  is  stout  and  shapeless,  or 
so  much  swollen  that  nothing  can  be  definitely  felt,  the  diffi- 
culty of  forming  an  exact  opinion,  of  making  absolutely  cer- 
tain at  once  that  the  joint  is  not  dislocated  or  the  bones  broken, 
may  be  easily  imagined. 

The  close  resemblance  that  exists  between  many  disloca- 
tions and  some  forms  of  sprains  ceases  to  be  astonishing  if  it 
is  remembered  that,  as  Vidal  de  Cassis  pointed  out,  they  are 
really  the  same  thing,  only  that  in  the  case  of  the  former  re- 
duction has  taken  place  spontaneously.  In  the  one  the  ar- 
ticular ends,  which  at  the  moment  of  the  accident  are  wrenched 
apart,  slip  back  again  into  their  natural  position  of  their  own 
accord ;  in  the  other  they  slip  still  further  aside. 


38  Sprains ;  their  Consequences  and  Treatment. 

Sprains  and  Fractures. — Ordinarily  speaking  there  is  not 
much  difficulty  in  distinguishing  sprains  from  fractures.  One 
may  easily  be  overlooked  when  both  are  present  at  the  same 
time,  especially  if  they  occur,  as  they  easily  may,  at  the  same 
spot ;  but  in  other  cases  the  signs  are  usually  distinctive.  The 
rough  grating  sensation  when  two  broken  ends  rub  against 
each  other,  the  undue  mobility,  deformity,  and  pain  present 
in  most  cases  of  fracture,  are  nearly  always  sufficient,  though, 
as  will  be  described  later,  some  of  these  signs  may  be  imitated 
exceedingly  well  by  other  conditions.  If,  however,  the  bones 
are  so  driven  into  each  other  by  the  violence  of  the  accident 
that  there  is  no  undue  mobility,  especially  if  in  addition  the 
line  of  fracture  runs  through  that  part  of  the  bone  which  lies 
immediately  inside  the  capsule  of  the  joint,  it  is  not  always 
easy  to  make  a  distinction. 

In  the  case  of  the  hip  this  is  well  known,  but  accidents  of  a 
similar  description,  with  or  without  impaction,  are  met  with 
sometimes  in  other  joints  as  well. 

Sprain  Fractures  of  the  Thumb. — The  thumb,  for  exam- 
ple, is  liable  to  a  peculiar  form  of  injury,  the  real  nature  of 
which  has  only  recently  been  explained.  It  follows  in  general 
a  severe  strain.  The  ball  of  the  thumb  swells  up  at  once,  and 
all  power  of  bending  it  into  the  palm  of  the  hand,  or  bringing 
it  towards  the  other  fingers,  is  lost.  On  the  back  of  the  bone, 
just  where  it  joins  the  wrist,  there  is  a  distinct  projection,  not 
nearly  so  large  as  it  would  be  if  the  joint  were  out,  and  recti- 
fied at  once  by  pressure,  only  as  soon  as  the  pressure  is  re- 
moved it  returns  again,  with  a  visible  and  painful  jerk.  If 
the  two  hands  are  compared  together  the  length  of  the  bones 
corresponds  exactly,  so  that  it  does  not  look  like  a  fracture; 
it  cannot  be  a  complete  dislocation,  and  a  partial  one  from 
the  structure  of  the  joint  is  impossible.  In  reality  the  injury 
partakes  of  the  nature  of  both.  There  is  an  oblique  fracture 
through  the  base  of  the  bone,  where  it  joins  the  wrist,  splitting 
off  that  part  which  lies  deeply  buried  under  the  muscles  of  the 
ball.  It  does  not  involve  the  back  of  the  bone,  so  that  the 
measurements  are  unaltered,  but  oAving  to  its  carrying  away 
with  it  the  projection  on  the  palmar  surface  that  serves  to 
make  the  joint  secure,  the  rest  of  the  bone  slips  back  and 
sticks  up  under  the  skin.  The  crepitus,  when  pressure  is  made 
from  front  to  back  on  the  ball  of  the  thumb,  and  the  broken 


Sprains ;   their  Consequences  and  Treatment.  39 

surfaces  are  rubbed  together,  can  be  felt  quite  easily,  and  the 
pain  is  greatly  increased  thereby.  The  ultimate  deformity,  if 
the  injury  is  not  diagnosed,  is  not  so  serious  as  might  be 
imagined,  but  the  movement  of  the  joint  is  interfered  with  for 
a  considerable  length  of  time. 


CHAPTER  IV. 

NATURE  OF  THE  INJURY. 

SPRAINS  differ  a  great  deal  both  in  the  nature  and  extent 
of  the  injury.  Sometimes  it  appears  to  be  quite  trivial ;  there 
is  merely  the  slipping4  of  a  disc  of  cartilage  from  between  two 
bones,  or  the  displacement  of  a  tendon  from  its  groove;  some- 
times everything-  that  holds  the  two  joint  surfaces  together, 
with  the  exception  of  the  skin,  is  torn  and  lacerated  as  it  is  in 
a  dislocation.  In  many  cases  the  injury  is  really  as  great: 
the  bones  are  wrenched  apart  from  each  other  at  the  moment 
of  the  accident,  only  instead  of  being  caught  and  held,  as  they 
are  in  a  dislocation,  they  fall  back  again  of  themselves  into 
their  natural  position.  Such  accidents  are  always  called 
sprains;  but  the  tissues  suffer  as  much  as  if  the  joint  had 
really  been  put  out. 

The  extent  to  which  the  tissues  are  torn  at  the  moment  is 
not  the  only  thing  that  has  to  be  taken  into  consideration. 
The  symptoms  and  the  after  consequences  are  often  most  seri- 
ous when  this  is  apparently  but  slight;  and  the  liability  to  in- 
flammation, and  other  troubles,  depends  a  great  deal  more  on 
the  constitution  of  the  patient,  and  the  way  in  which  the 
sprained  joint  is  treated,  than  on  the  number  or  size  of  the 
structures  that  are  torn.  So  long  as  the  natural  process  of 
healing  is  still  in  its  full  vigor,  as  in  children  and  young  adults, 
injuries,  no  matter  how  serious  they  are,  are  repaired  without 
the  least  difficulty.  The  treatment  must  be  well  planned,  it  is 
true,  and  thoroughly  carried  out;  proper  care  must  be  taken 
that  the  parts  are  not  subjected  to  too  severe  a  strain  before 
they  can  stand  it;  but  if  this  is  done,  after  consequences  of 
any  kind  are  the  exception.  Unhappily  as  time  goes  on  the 
effects  of  age  and  of  constitutional  frailties  become  so  power- 
ful that  in  many  cases,  in  spite  of  every  care,  a  comparatively 
trivial  injury  often  leads  to  the  most  serious  results,  and  re- 


Sprains ;  their  Consequences  and  Treatment.  41 

covery  is  delayed  indefinitely,  or  remains  imperfect  perhaps 
for  the  rest  of  life. 

Opportunities  for  examining1  joints  shortly  after  they  have 
been  sprained  are  not  very  common,  though  they  occur  some- 
times when  a  patient  has  received  other  and  more  serious  dam- 
age in  the  same  accident.  By  taking  advantage  of  these  a 
fair  amount  of  information  has  been  obtained  with  regard  to 
ordinary  cases ;  and  the  results  have  been  confirmed  by  Bon- 
net, of  Lyons,  and  others,  who  have  made  use  of  other  methods. 
Many  special  sprains,  however,  such,  for  example,  as  the  in- 
ternal derangement  of  the  knee-joint,  first  described  by  Hey, 
are  still  involved  in  a  certain  amount  of  obscurity.  They  are 
not  uncommon ;  for  years  past  they  have  attracted  an  unusual 
amount  of  attention  from  the  inconvenience  they  cause,  and 
the  striking  character  of  the  symptoms  that  attend  them ;  but 
the  joints  in  which  they  occur  are  so  complicated,  and  oppor- 
tunities for  examining  them  so  rare,  that  there  is  not  as  yet 
any  settled  opinion  as  to  what  the  nature  of  the  accident  may 
be.  It  does  not  seem  unlikely  that  the  actual  displacement 
varies  in  different  cases,  even  though  the  external  symptoms 
are  to  all  appearance  the  same. 

Generally  speaking,  the  tissues  on  one  side  of  a  joint  are 
overstretched  and  torn;  those  on  the  other  compressed  and 
crushed  together;  but  there  is  always  so  much  twisting,  and 
such  a  difference  in  the  strength  and  power  of  resistance  of 
the  various  structures,  that  unless  the  part  is  examined  with 
the  greatest  care  it  is  almost  impossible  to  say  what  actually 
has  given  way.  In  every  case  no  pains  should  be  spared  to 
find  out  the  whole  of  the  mischief  with  as  little  delay  as  possi- 
ble. There  are  many  instances  on  record  in  which  delayed 
convalescence  has  been  due  solely  to  the  fact  that  a  displaced 
tendon  or  other  structure  has  not  been  recognized  sufficiently 
early.  The  difficulty  increases  with  every  minute.  Immedi- 
ately after  a  sprain,  before  the  position  of  the  parts  has  been 
altered  by  attempts  at  movement,  or  concealed  by  swelling, 
the  nature  of  the  displacement  may  often  be  recognized  with- 
out much  trouble.  But  if  the  chance  is  lost,  the  part  begins 
to  throb  with  pain,  swelling  sets  in  and  obscures  everything, 
and  it  is  often  necessary  either  to  place  the  patient  under  an 
anaesthetic  or  to  wait  until  the  extravasation  a  ad  oedema  have 
been  dispersed. 


42  Sprains ;  their  Consequences  and  Treatment, 

Haemorrhage  into  the  Sac. — Most  of  the  swelling  that 
makes  its  appearance  immediately  is  due  to  the  blood  that 
pours  out  from  the  torn  vessels.  The  central  cavity  of  the 
joint  becomes  distended  with  fluid,  which  varies  in  character 
and  amount  according"  to  the  number  and  size  of  the  vessels 
in  the  injured  part,  and  the  length  of  time  that  has  elapsed 
since  the  accident.  If  the  swelling  reaches  its  maximum 
within  the  first  few  hours,  it  is  probably  due  mainly  to  blood ; 
if  twenty-four  hours  pass  by  before  this,  there  is  a  large  pro- 
portion of  lymph  mixed  with  it,  and,  at  the  same  time,  if  the 
joint  is  superficial,  some  heat  and  redness  of  skin.  The  amount 
is  very  variable;  sometimes  it  is  not  easy  to  detect  any  in- 
crease at  all;  at  others,  especially  if  no  steps  have  been  taken 
to  check  it,  the  distention  is  so  great  that  the  outline  of  the 
synovial  sac  may  be  traced  distinctly  beneath  the  skin.  The 
delicate  structures  lining  the  cavity  are  torn  and  bruised,  and 
the  vessels  continue  to  bleed  until  the  contraction  of  their 
walls  and  the  pressure  of  the  fluid  accumulating  round  them 
stops  the  flow.  Probably  the  blood  soon  coagulates,  as  it  does 
when  extravasated  into  other  tissues  of  the  body;  and  at  a 
somewhat  variable  period  becomes  liquid  again.  At  least,  if 
a  joint  is  tapped  or  aspirated  a  few  days  after  a  severe  sprain, 
it  is  found  to  contain  a  fluid,  which,  though  it  still  reddens  on 
exposure  to  air,  differs  from  blood  -in  color,  and  in  being  turbid 
from  floating  debris.  If  left  to  itself,  the  quantity  diminishes, 
and  it  undergoes  other  changes.  The  coloring  matter  slowly 
soaks  into  the  tissues  round,  so  that  they  remain  deeply  stained 
for  weeks;  the  floating  fragments  become  finer  and  finer,  until 
they,  too,  disappear;  and  at  length,  though  the  amount  re- 
mains excessive  for  a  considerable  time,  it  assumes  again  the 
character  of  the  natural  synovial  fluid. 

The  rent  in  the  capsule  may  be  almost  imperceptible,  merely 
a  superficial  line,  extending  across  part  of  the  cavity,  and  only 
marked  by  an  uneven  band  of  discoloration;  or  it  may  stretch 
right  across  from  one  side  to  the  other,  and  open  up  the  cellu- 
lar spaces  round.  It  is  especially  liable  to  give  way  along  the 
line  of  its  attachment  to  the  bone,  and  as  this  is  where  the 
blood-vessels  are  largest  and  most  abundant  it  accounts  in 
some  measure  for  the  amount  of  the  haemorrhage.  At  this 
point  there  is  a  considerable  thickness  of  soft  loose  tissue  with 
little  resisting  power,  and  the  fibres  are  more  widely  spread 


Sprains ;  their  Consequences  and  Treatment.  43 

out  and  separated  from  each  other  than  they  are  elsewhere, 
so  that  when  a  strain  falls  on  them  it  attacks  them,  as  it  were, 
in  detail,  and  easily  overcomes  them.  It  is  very  unusual  not 
to  find  some  evidence  of  violence,  some  staining-  or  reddening1 
at  this  point,  after  a  joint  has  been  sprained. 

Hcemorrhage  in  the  Synovial  Wall. — The  extravasation 
is,  however,  not  limited  to  the  interior.  If  the  cavity  is  opened 
there  are  patches  of  it,  apparently  adherent  to  the  inner  wall, 
but  really  situated  within  its  substance,  covered  over  by  so 
delicate  a  film  of  tissue  that  they  can  be  plainly  seen  through 
it.  Most  of  these  disappear  at  length.  They  merely  leave  a 
thickened  and  discolored  spot,  which,  as  a  rule,  is  well  out  of 
the  way,  and  causes  no  inconvenience.  If,  however,  they  occur 
in  a  part  of  the  joint  where  the  lining-  membrane  is  loose  and 
thrown  into  folds  when  at  rest,  or  where  there  are  many 
fringes  and  outgrowths  well  protected  from  pressure,  as  round 
the  neck  of  a  bone,  they  sometimes  lead  to  great  annoyance. 
A  hard,  unyielding  patch  is  formed  in  the  smooth  and  supple 
wall;  its  flexibility  is  lost,  and  it  cannot  yield  itself  kindly  to 
the  movements  of  the  joint,  but  drags  on  the  other  parts,  and 
:.cts  as  a  continual  source  of  irritation  and  pain. 

These  changes  are  not  confined  to  sprains;  -they  occur  after 
other  injuries  with  almost  equal  frequency,  and  may  always 
be  suspected  when,  long  after  an  accident,  some  particular  or 
unusual  spot  remains  tender,  or  one  special  movement  is  lim- 
ited in  extent.  The}-  are  particularly  common  in  the  deeper 
layers.  The  soft  cellular  pads  that  are  developed  in  and  round 
joints,  for  the  purpose  of  filling-  up  spaces  that  vary  in  size 
with  every  movement,  are  generally  deeply  stained  with  blood. 
If  this  is  absorbed  again  no  ill  result  follows;  but  it  often  hap- 
pens, from  the  soft  and  yielding-  nature  of  the  tissues  at  these 
places,  and  from  the  way  in  which  they  are  protected  from 
pressure,  that  when  a  joint  is  kept  at  rest  in  one  position  this 
is  never  thoroughly  carried  out.  The  blood  remains  for  a  long 
time  without  changing,  and  then  slowly  becomes  organized 
into  a  dense,  unyielding  mass.  The  pad  which  was  intended 
to  give  way  before  the  faintest  pressure,  and  accommodate 
itself  to  every  change  of  position,  becomes  hard  and  dense, 
and  moulded  to  one  form.  So  long  as  the  limb  remains  at 
rest  it  is  fairly  comfortable;  as  soon  as  it  is  moved  there  is 
pain,  because  the  pressure  is  no  longer  distributed  evenly  over 
the  whole  surface. 


44  Sprains ;  their  Consequences  and  Treatment. 

Bursce. — Changes  of  a  similar  character  are  very  prone  to 
occur  where  there  are  spaces  near  joints,  in  which  blood  or 
other  fluids  collect  after  injuries.  They  may  be  bursse  or 
mere  interspaces  in  the  cellular  tissue,  without  any  well- 
marked  limit;  some  are  definite  in  shape  and  position,  exist- 
ing1, at  least  in  adults,  in  all  alike;  but  many  are  accessory, 
developed  here  and  there  by  the  accidental  friction  of  one 
structure  on  another,  and,  therefore,  differing  in  size  and  shape 
and  position  in  each  individual.  Whatever  they  are,  they  act 
as  receptacles  for  the  blood  which  is  extravasated  into  the 
tissues  after  sprains  and  other  injuries.  It  collects  in  them 
and  distends  them,  lining  their  interior  with  a  layer  of  false 
membrane,  which  slowly  becomes  organized  and  makes  their 
wall  dense  and  hard.  Then  they  become  tender  and  painful; 
their  surfaces  are  roughened  and  irregular;  they  obstruct  in- 
stead of  assisting  the  movement  of  one  part  on  another;  and 
often,  by  inducing  the  patient  to  keep  the  part  at  rest,  they 
lead  to  other  changes,  the  importance  of  which  is  altogether 
out  of  proportion  to  the  severity  of  the  original  injury. 

Some  of  these  bursal  swellings  are  very  perplexing.  In 
many  cases  where  there  is  a  large  cavity  overlying  a  joint  it 
is  very  difficult  to  tell  whether  the  fluid  is  really  in  the  synovial 
sac  of  the  joint  or  outside  it.  It  may  reproduce  the  shape  ex- 
actly, and  by  its  tension  prevent  the  muscles  from  contracting 
as  much  as  if  the  capsule  itself  were  distended. 

In  others,  especially  when  the  swelling  is  recent,  and  there 
is  something  firm  behind,  such  as  a  bone  or  the  wall  of  the 
chest,  the  imitation  of  a  fracture  is  surprisingly  good.  There 
is  a  sensation  of  crackling,  when  the  part  is  handled,  closely 
similar  to  that  produced  by  rubbing  together  the  two  ends  of 
a  broken  bone.  It  is  really  due  to  the  dense  fluid  being  pressed 
through  the  mesh  work  of  connective-tissue  interspaces  which 
make  up  the  interior  of  most  of  these;  and  it  may  nearly 
always  be  distinguished  (independently  of  the  absence  of  the 
other  signs  of  fracture)  by  the  difficulty  there  is  in  eliciting  it 
a  second  time,  until  either  the  fluid  is  driven  back  again  or 
some  more  allowed  to  accumulate.  There  is  no  difficulty  in 
feeling  it  once,  but  it  is  very  hard  to  demonstrate  it  to  another 
person. 

When  extravasated  blood  collects  in  the  space  between  the 
shoulder-blade  and  the  back  the  sensation  is  most  deceptive. 


Sprains ;   their  Consequences  and  Treatment.  45 

I  have  known  many  instances  in  which  a  mistake  has  been 
made  through  relying  on  this,  fractures  of  various  parts  of 
bone  having-  been  diagnosed,  in  spite  of  the  absence  of  displace- 
ment and  of  tenderness  on  pressure.  This  occurs,  too,  in  other 
situations.  In  one  case  in  particular  the  patient,  who  had  on 
a  previous  occasion  suffered  from  several  fractures  in  different 
parts  of  his  bod}-,  was  so  firmly  convinced  that  his  collar-bone 
was  broken  that  nothing  could  make  him  believe  the  contrary. 
He  had  sustained,  certainly,  a  severe  fall  on  his  shoulder,  and 
was  badly  bruised;  there  was  great  difficulty  in  raising  his 
arm  from  the  side,  and  the  whole  region  was  much  swollen; 
but  there  was  no  displacement  of  any  kind,  and  the  tenderness 
was  general,  not  limited  to  any  one  definite  spot,  as  it  would 
have  been  in  the  case  of  a  fracture.  On  manipulation,  how- 
ever, the  most  distinct  crepitus  would  be  obtained,  especially 
when  the  arm  was  lifted  up,  and  the  shoulder  grasped  firmly 
from  before  backward  by  the  finger  and  thumb;  and  it  was 
so  definite  in  character,  and  so  perceptible  to  the  patient,  that 
he  was  absolutely  sure  that  it  came  from  his  collar-bone.  Not 
until  ten  days  had  passed,  when  he  could  use  his  limb  freely 
in  all  directions  without  pain,  would  he  admit  that  the  fract- 
ure (if  it  was  one)  had  united  very  much  more  rapidly  than 
those  he  had  sustained  on  a  previous  occasion. 

In  this  case  there  was  undoubtedly  a  large  extravasation 
of  blood  into  the  bursa  which  covers  in  the  shoulder  joint. 
Very  likely  its  walls  were  torn,  or  crushed  and  bruised  with 
some  of  the  muscular  fibres  lying  over  it.  Raising  the  arm 
pressed  its  sides  together,  so  that  the  fluid  was  driven  from 
one  part  to  another,  and  squeezed  among  the  irregular  meshes 
that  lined  the  interior.  Later  on  this  was  absorbed;  the 
staining  made  its  appearance  in  the  usual  situation,  under  the 
borders  of  the  deltoid,  and  as  there  was  no  permanent  thick- 
ening or  rigidity  of  the  walls,  movement  was  completely  re- 
gained. All  cases  are  not  so  fortunate.  It  is  not  uncommon 
to  find  the  interior  of  this  bursa  lined  in  all  directions  with 
shaggy  villous  projections,  hanging  down  in  the  cavity,  the 
result  of  repeated  injury  or  inflammation,  and  the  cause  of 
constant  inconvenience  and  even  pain. 

The  Ligaments. — The  extent  to  which  the  ligaments  are 
injured  varies  quite  as  much.  It  is  no  uncommon  thing  to 
find  the  strongest  in  the  body,  such  as  the  internal  lateral 


46  Sprains;  their  Consequences  and  Treatment. 

ligament  of  the  knee  or  ankle,  completely  torn  across,  and  the 
joint  as  full  of  blood  as  it  can  be;  or,  on  the  other  hand,  there 
may  be  scarcely  a  bruise  or  tear.  They  are  really  part  of  the 
capsule  uniting  tog-ether  the  ends  of  the  bones.  The  structure 
is  the  same  in  all  essential  particulars,  and  they  are  practically 
continuous;  only  the  arrangement  is  different;  in  the  one,  the 
fibres  are  scanty  and  weak,  with  many  and  large  inter-flbrillar 
spaces;  in  the  other,  they  are  arranged  in  closely  woven  bun- 
dles, parallel  to  each  other,  and  so  tense  as  scarcely  to  admit 
of  any  elongation  by  sudden  violence.  They  may  tear,  es- 
pecially small  portions  of  them  here  and  there,  so  that  the 
whole  thickness  is  not  broken  across  at  any  one  spot;  but  they 
will  not  stretch.  It  is  true  that  under  certain  conditions  they 
do  become  elongated,  but  this  only  happens  when  the  strain  is 
continuous,  and  lasts  for  some  considerable  time.  A  slight 
degree  of  inflammation  sets  in  then,  and  under  its  influence 
the  fibrils  soften  until  they  yield 

Sometimes  ligaments  give  way  in  the  middle,  but  it  is  more 
common  for  them  to  separate  from  the  bone,  or  to  wrench 
from  it  a  small  thin  scale  corresponding  to  their  attachment. 
This  is  due  in  part  to  the  arrangement  of  their  fibres.  In  the 
centre  they  are  woven  closely  together,  and  form  a  rounded 
bundle  of  great  strength;  at  the  ends  they  spread  out  like  a 
fan,  so  as  to  secure  a  wider  attachment.  By  this  their  mutual 
support  is  lost,  and  the  course  of  the  fibres  is  altered,  so  that 
the  direction  of  the  strain  no  longer  coincides  equally  well  with 
that  of  all  the  strands.  Owing  to  this  they  give  way  much 
more  easily.  A  ligament  that  can  resist  successfully  a  straight 
pull  of  great  violence  yields  at  once  to  a  twisting  force  of 
much  less  severity,  because  this  falls  on  the  fibres  unequally, 
one  by  one,  and  tears  them  from  their  attachment. 

Intra-articular  Ligaments. — Some  of  the  structures  that 
lie  in  the  interior  of  joints  occasionally  suffer  in  a  peculiar 
manner.  Inter-osseous  ligaments,  formed  of  very  short  nu- 
merous bands  of  fibres  connecting  immediately  two  roughened 
bony  surfaces,  rarely  give  way,  owing  to  their  great  strength, 
the  bone  yielding  instead;  but  the  discs  of  nbro-cartilage, 
which  are  interposed  in  places  between  the  bones  for  the  pur- 
pose of  deepening  the  sockets,  and  modifying  the  effect  of 
shocks,  are  very  liable  to  suffer.  Sometimes  they  are  bruised 
or  crushed ;  more  often  they  are  torn  from  their  attachments 


Sprains ;   their  Consequences  and  Treatment.  47 

and  displaced,  so  that  they  interfere  with  the  working  of  the 
joint.  Or,  without  being-  actually  separated,  they  may  be  so 
stretched  that  the  result  is  much  the  same.  This  is  best 
known  in  the  knee;  in  other  joints  in  which  discs  of  this  kind 
are  found  they  are  so  much  smaller  and  so  firmly  fixed  that 
they  rarely  give  rise  to  any  inconvenience.  In  the  knee  they 
are  very  large;  their  normal  range  of  movement  is  very  con- 
siderable, and  they  are  so  loosely  held  that  displacement  is 
not  only  easy,  but,  when  it  has  once  been  produced  (owing  to 
the  feebleness  with  which  repair  takes  place),  is  always  liable 
to  occur  again. 

The  Knee. — I  am  not  aware  that  there  has  ever  been  an 
opportunity  for  examining  the  interior  of  a  knee  joint  shortly 
after  this  had  happened  for  the  first  time,  and  before  the  disc 
has  been  replaced.  Indeed,  from  the  nature  of  the  accident,  it 
is  scarcely  likely  there  could  be  such,  except  under  the  strang- 
est coincidence;  but  on  several  occasions  the  joint  has  been 
opened  and  the  displacement  verified  after  it  has  occurred  re- 
peatedly. And  often  the  patient  is  aware  of  a  projection  from 
the  side  of  the  knee,  caused  by  the  displaced  disc.  There  is, 
therefore,  no  question  as  to  the  nature  of  the  accident,  but,  as 
has  been  already  mentioned,  it  is  by  no  means  certain  that 
this  explanation  serves  for  all  the  various  forms  of  internal 
derangement  that  have  been  described,  even  when  full  allow- 
ance is  made  for  the  different  directions  in  which  it  may  take 
place. 

The  Fingers. — The  finger  joints,  again,  are  the  seat  of  a 
peculiar  kind  of  injury  somewhat  similar  to  this.  They  all  of 
them  belong  to  the  class  of  hinge-joints,  admitting  free  move- 
ment so  far  as  flexion  is  concerned,  but  exceedingly  little  in  any 
other  direction.  On  the  under  surface  of  each  there  is  a  plate 
of  fibro-cartilage,  similar  in  structure  to  the  discs  hi  the  knee 
joint,  and,  like  them,  helping  to  deepen  the  socket  hi  which 
the  head  of  one  bone  rotates.  In  fact,  this  is  the  chief  bond  of 
union  between  the  bones,  but  while  it  is  so  firmly  united  to 
one  that  it  is  almost  impossible  to  tear  it  off  with  any  reason- 
able degree  of  force,  the  fibrous  tissue  that  binds  it  to  the 
other  is  soft  and  flexible,  so  as  not  to  interfere  unduly  with 
the  action  of  the  joint.  Sometimes  it  happens  in  severe 
wrenches,  especially  when  the  finger  is  forced  backward,  that 
this  plate  of  cartilage  is  torn  from  its  attachment,  and  slips 


48  Sprains;  their  Consequences  and  Treatment. 

up  between  the  bones,  so  that  when  the  force  is  past  they  can- 
not resume  their  natural  position. 

Mitchell  Banks  has  shown  how  this  occurs  in  the  joint  be- 
tween the  index  finger  and  the  hand,  in  which  it  is  most  com- 
mon; and  I  have  met  with  several  instances,  not  only  there, 
but  in  other  joints  also.  It  is  an  exceedingly  painful  accident, 
often  causing  fainting  and  sickness.  The  deformity  is  very 
conspicuous,  especially  in  the  back  of  the  joint,  though  it  is  not 
so  great  as  that  of  a  true  dislocation  or  when  a  bone  is  broken. 
The  finger  is  kept  slightly  bent.  By  using  the  other  hand  the 
patient  can  move  it  through  a  considerable  angle,  but  he  can- 
not either  straighten  it  out  or  bend  it  thoroughly  into  the  palm. 
No  amount  of  force  produces  any  effect  in  the  displacement;  it 
is  due  to  the  cartilage  which  has  slipped  between  the  ends  of 
the  bones  and  prevents  them  moving  freely  on  each  other. 
Until  this  is  released  from  its  position  the  deformity  must 
remain  unrelieved.  If  left  to  itself  the  finger  generally  re- 
covers a  good  deal  of  its  power,  but  the  appearance  is  very 
unsightly. 

The  Muscles. — The  muscles  round  joints  rarely  escape  when 
the  sprain  is  severe,  though  the  injury  may  at  first  be  masked 
by  other  symptoms.  Sometimes  it  is  very  serious,  but  this 
depends  probably  on  their  condition  at  the  moment  of  the  ac- 
cident. If  they  are  firmly  contracted  and  ready  to  resist,  the 
joint  does  not  suffer  unless  they  are  overcome,  and  then  the 
injury  is  generally  too  great  to  be  called  a  sprain.  Most  often 
they  are  taken  by  surprise,  and  are  hurt  more  by  their  own 
sudden  and  spasmodic  effort  at  recovery  than  by  anything  else. 

The  weakest  part  of  a  muscle  varies  a  good  deal  according 
to  its  shape.  When  they  are  short  and  broad,  with  wide  at- 
tachments to  the  bones  and  firmly  bound  down  by  sheets  of 
fibrous  tissue,  there  does  not  seem  to  be  any  definite  rule. 
Probably  the  part  that  gives  way  first  is  determined  mainly 
by  individual  peculiarities  of  structure;  but  when  they  are  of 
considerable  length,  and  attached  to  distant  bones  by  rounded 
tendons,  the  weakest  part  is  the  line  of  junction  between  the 
muscular  fibres  and  the  connective  tissue.  It  is  at  this  point 
that  they  tear,  causing  a  great  extravasation  of  blood,  and 
giving  rise  to  a  swelling  which  at  first  is  soft  and  fluctuating, 
but  which  soon  becomes  hard  and  solid,  and  may  persist  in  that 
condition  for  an  almost  indefinite  period. 


Sprains ;   their  Consequences  and  Treatment.  49 

This  often  happens  when  the  fibres  are  torn  across,  while 
the  dense  unyielding-  sheath  that  surrounds  them  remains  in- 
tact. The  extravasated  blood  is  tightly  bound  down,  and 
forms  a  hard  resisting-  nodule,  the  nature  of  which  can  only 
be  ascertained  by  the  rapidity  with  which  it  occurs  and  the 
way  in  which  it  is  confined  to  the  limits  of  the  muscle.  I  have 
recently  had  under  my  care  a  patient  with  a  nodule  of  this 
kind  in  one  of  the  muscles  of  the  neck  just  where  the  tendinous 
and  muscular  fibres  meet.  It  made  its  first  appearance  quite 
suddenly  during-  a  violent  effort,  with  all  the  characteristic 
signs  of  muscular  rupture,  more  than  a  year  before,  but  in 
spite  of  energetic  treatment  by  massage  and  other  methods  it 
was  nearly  three  months  before  it  finally  disappeared. 

When  a  muscle  gives  way  completely,  it  is  usually  at  the 
same  spot.  A  curious  instance  of  this  is  not  uncommon  among 
butchers.  They  occasionly  lose  the  last  joint  of  their  thumb 
by  catching  it  in  a  hook  and  tearing  it  off.  The  skin  and  the 
ligaments  give  way  at  the  seat  of  injury,  but  the  tendons  of 
the  muscles  retain  their  connection  with  the  bones.  The  long- 
flexor  is  pulled  out  of  its  sheath  for  five  or  six  inches,  one  end 
remaining  attached  to  the  bone,  the  other  bringing-  away  with 
it  torn  shreds  of  the  muscular  fibres  that  have  given  way  above 
the  wrist. 

Rider's  Sprain. — Sometimes  the  muscles  are  torn  and 
strained  without  the  joints  being  hurt  at  all.  Those,  for  ex- 
ample, that  lie  on  the  inner  side  of  the  thigh  occasionally  give 
way  under  the  semi-voluntary  grip  by  which  a  rider  secures 
his  seat  when  his  horse  swerves  or  bolts  round.  There  is  a 
sudden  sharp  contraction,  a  sensation  of  something-  giving  way, 
and  a  feeling-  that  the  hold  on  the  saddle  is  g-one.  A  dull  ach- 
ing- pain  sets  in  at  once,  and  grows  worse  and  worse  with  every 
attempt  to  proceed;  the  part  begins  to  swell  as  the  blood 
pours  out  from  the  torn  vessels;  a  peculiar  warm  trickling 
sensation  is  felt  down  the  inner  side  of  the  leg-,  and,  as  a  rule, 
the  rider  is  compelled  to  dismount.  When  standing,  the  symp- 
toms are  not  quite  so  severe,  but  the  least  attempt  to  bring 
that  group  of  muscles  into  play  again,  or  to  remount,  makes 
them  tenfold  worse. 

The  kind  of  injury  is  well  known,  and  is  usually  recognized 
at  once.  It  is  due  to  the  rupture  of  the  tendon  that  stands 
out  under  the  skin  on  the  inner  side  of  the  thigh ;  sometimes  it 


50  Sprains ;   their  Consequences  and  Treatment. 

gives  way  near  the  bone,  so  that  the  gap  can  be  felt,  but  more 
often  the  muscular  fibres  are  torn  away  from  it  without  leav- 
ing1 any  distinct  interval.  The  extravasation  is  often  very  ex- 
tensive, and  it  may  be  weeks  before  the  last  traces  of  the 
staining  finally  disappear.  Every  endeavor  must  be  made  to 
keep  it  as  much  as  possible  within  bounds.  A  stirrup  leather 
may  be  tied  tightly  round  the  part  as  a  temporary  measure; 
but  a  much  more  effectual  method  is  to  buckle  a  long  strap  of 
webbing  round  the  thigh,  outside  the  breeches.  It  must  be 
well  padded,  on  the  inner  side,  over  the  point  where  the  muscle 
is  torn,  and  coming  up  in  front  and  behind,  should  cross  over 
the  hip  and  be  carried  round  the  waist.  Where  the  laceration 
is  complete,  some  such  appliance  may  be  permanently  required. 

Eider's  Bone. — A  long  slender  spine  of  bone  which  is  oc- 
casionally met  with  in  connection  with  these  tendons  probably 
has  its  origin  in  the  same  kind  of  injury.  It  is  known  as 
rider's  bone,  from  its  being  found  chiefly  in  those  who  have 
spent  a  large  proportion  of  their  lives  in  the  saddle.  Some- 
times it  causes  a  good  deal  of  inconvenience  by  the  way  in 
which  it  interferes  with  the  flexibility  of  the  part;  but  more 
often  its  existence  is  hardly  known,  as  it  lies  buried  in  the  sub- 
stance of  the  tendon  itself.  If  the  history  is  inquired  into,  it  is 
always  said  to  have  developed  after  one  single  severe  strain; 
but  comparing  it  with  similar  formations  in  other  tendons,  it 
seems  more  probable  that  it  is  due  to  the  constant  bruising  to 
which  the  muscles  are  subjected.  Probably  it  is  formed  from 
the  organization  of  lymph  thrown  out  from  time  to  time. 

Rider's  Bursa. — Other  troubles  also  are  produced  in  this 
way.  A  soft  fluctuating  swelling  sometimes  makes  its  ap- 
pearance underneath  the  tendon,  high  up  in  the  groin.  So 
long  as  the  muscle  is  in  action  it  is  tense  and  firm,  as  soon  as 
it  is  relaxed  it  becomes  soft  and  flaccid ;  but  it  cannot  be  dis- 
persed, or  even  reduced  in  size,  by  pressure.  In  one  case  under 
my  care,  considerable  improvement  was  effected  by  rest  and 
blistering,  but  I  am  afraid  it  was  not  permanent.  The  patient 
was  a  man  who  had  been  accustomed  to  a  great  deal  of  rough 
riding,  and  it  seemed  to  cause  him  considerable  annoyance. 
The  thing  of  which  he  complained  most  was  a  sensation  of 
weakness,  similar,  apparently,  to  that  which  is  so  often  ex- 
perienced in  the  hand  when  there  is  a  ganglion  on  the  back  of 
the  wrist;  but  it  was  doubtful  if  there  was  any  actual  loss  of 


COLL" 

Sprains;  their  Consequences  and  Treatment.  51 

power.  The  swelling-  had  made  its  appearance  slowly,  and  was 
still  increasing1  when  he  came  to  see  me,  so  that  it  evidently  was 
not  due  to  any  extravasation.  Most  probably  it  resulted  from 
the  effusion  poured  out  after  repeated  strains;  and,  as  he  could 
not  give  up  his  occupation,  it  is  certain  to  increase,  until  it 
ends  either  in  inflammation  and  suppuration  or  else  in  the  for- 
mation of  a  bursa. 

Lawn  Tennis  Leg. — Lawn  tennis  leg-  is  another  instance. 
This  was  a  well-known  form  of  accident  long1  before  lawn  tennis 
was  ever  played;  but  it  has  become  so  much  more  common, 
as  the  game  has  grown  popular,  that  perhaps  the  name  is  not 
inappropriate.  It  is  most  frequently  met  with  in  men,  es- 
pecially in  those  who,  as  youth  passes  by,  are  beginning-  to  in- 
crease in  weight,  and  whose  muscles  are  somewhat  out  of 
training;  but  not  improbably  there  are  other  causes  too.  It 
is  decidedly  rare,  for  instance,  among  the  laboring  classes;  I 
am  not  aware  myself  of  having  seen  any  example  among  the 
out-patients  at  hospitals ;  and,  whether  it  is  worth  anything  or 
not,  it  is  certain  that  in  a  very  large  proportion  of  the  cases 
some  evidence  of  gout  may  be  found,  not  necessarily  of  any 
very  acute  attack,  but  merely  of  those  indefinite  forerunners 
which  are  often  quite  as  distinctive.  Generally  speaking,  it 
occurs  during  some  sudden  and  violent  effort,  a  sudden  spring 
forward  to  take  a  ball,  for  example;  but  the  merest  slip  is 
enough.  Indeed,  in  some  cases  it  is  so  difficult  to  obtain  a 
definite  history  of  such  an  accident  that  I  am  rather  sceptical 
as  to  its  really  being  required.  I  have  known  at  least  one  in 
which  it  occurred  while  the  patient  was  walking  along  a  level 
road,  on  which  there  was  not  even  a  projecting  stone. 

The  symptoms  are  exceedingly  characteristic.  All  of  a 
sudden  there  is  a  sharp  stab  of  pain  in  the  calf  of  the  leg;  the 
patient  stops  instantaneously,  lifts  his  foot  from  the  ground, 
and  nearly  always  looks  round  to  see  if  some  one  has  not  struck 
him  a  violent  blow  with  a  stick  or  a  stone.  Rest  his  weight 
on  the  leg  he  cannot ;  the  pain,  it  is  true,  does  not  continue 
with  the  same  intensity,  but  the  recollection  is  such  that  noth- 
ing will  induce  him  to  try.  When  the  part  is  examined,  there  is 
generally  nothing  to  be  seen;  but  there  is  an  exceedingly  ten- 
der spot  in  the  substance  of  the  calf,  and  sometimes  a  slight 
depression  can  be  felt.  Later  on,  marks  of  bruising  make  their 
appearance,  yellow  at  first,  but  gradually  becoming  darker  as 


MJOO 

.MCM-14 
Sprains ;  their  Consequences  and  Treatment. 

the  coloring-  matter  approaches  the  surface,  and,  generally 
speaking,  most  plain  toward  the  lower  part  of  the  leg,  even 
when  the  painful  spot  is  nearer  to  the  knee.  This,  however, 
is  liable  to  be  modified  considerably  if  the  part  is  well  band- 
aged. In  one  or  two  cases  I  have  noted  a  slight  degree  of 
puffy  swelling  behind  the  ankle,  and  it  is  said  that  occasionally 
the  foot  is  deflected  somewhat  from  the  straight  line ;  but  this 
I  have  never  seen  myself,  and  I  should  feel  inclined  to  assign 
it,  when  it  is  present,  to  secondary  changes  taking  place  in 
the  smaller  joints  of  the  foot,  consequent  on  the  very  unequal 
and  unfair  degree  of  strain  thrown  on  them. 

The  usually  received  explanation  of  this  very  striking-  acci- 
dent is  that  it  is  the  result  of  the  rupture  of  an  exceedingly 
small  muscle,  known  as  the  plantaris,  situated  in  the  substance 
of  the  calf  of  the  leg-.  The  muscle  itself  is  in  many  respects 
most  peculiar;  it  is  very  deeply  placed,  lying  under  the  largest 
muscle  of  the  calf,  is  itself  exceedingly  short  and  weak,  being- 
rarely  three  inches  long,  and  is  provided  with  a  prodigiously 
long  tendon,  which  either  joins  the  tendo  Achillis  at  the  back 
of  the  heel,  or  else  is  attached  to  the  bone  in  close  proximity  to 
it.  Whether  rupture  of  such  a  structure  can  take  place  or  not 
is  almost  impossible  to  prove ;  the  fact  is  commonly  asserted, 
and  it  is  usually  admitted  as  an  explanation  of  the  symptoms, 
but  I  am  not  aware  of  any  instance  in  which  it  has  been  actu- 
ally shown.  It  is  quite  certain  that  the  same  effect  may  be 
produced  by  other  causes. 

This  explanation,  for  example,  does  not  answer  when  the 
same  accident  occurs  twice  in  the  same  leg-  at  different  places. 
A  striking-  instance  of  this  recently  came  under  my  notice,  the 
interval  between  the  two  occurrences  being  only  a  few  weeks. 
On  the  first  occasion  the  middle  of  the  calf  of  the  leg-  was  the 
part  involved;  on  the  second  it  was  at  least  four  inches  lower 
down,  and  nearer  to  the  ankle.  Nor  was  this  to  be  explained 
as  the  rupture  of  muscular  adhesions  that  had  developed  dur- 
ing- the  period  of  convalescence ;  for  not  only  had  there  been 
nothing  to  occasion  them  in  this  locality,  but  recovery  was  / 
practically  perfect,  so  that  the  patient  could  walk  without  in-  { 
convenience,  and  without  any  apparent  limping.  The  second 
accident  was  precisely  of  the  same  nature  as  the  first ;  there 
was  the  same  sharp  stab  of  pain,  with  tenderness,  and  a  slight 
amount  of  swelling,  and  the  same  feeling  that  it  was  impossible 


Sprains ;  their  Consequences  and  Treatment.  53 

to  place  the  foot  upon  the  ground ;  but  clearly  it  could  not  be 
due  to  the  tendon.  This,  if  it  had  united  at  all,  could  not  have 
been  sufficiently  firm  to  withstand  a  strain  that  compelled  it 
to  give  way  at  another  part.  The  scar  could  not  have  been  so 
strong  as  the  original  structure. 

W.  Hood  (Lancet,  1884)  considers  that  it  is  the  result  of 
the  rupture  of  some  portion  of  the  muscular  or  tendinous 
structure  of  the  calf,  without  specifying-  it  more  particularly ; 
and  no  doubt  this  is  correct  in  many  instances,  especially  when 
a  depression  can  be  felt  by  the  finger  where  the  fibres  have 
given  way.  Rupture  of  the  plantaris,  which  is  comparatively 
a  deeply-seated  muscle,  could  never  cause  this.  I  would  vent- 
ure to  suggest,  however,  that,  in  those  cases  at  least  in  which 
the  amount  of  blood  extravasated  is  considerable,  the  cause  is 
connected  with  the  condition  of  some  of  the  deep  intermuscu- 
lar  veins.  In  many  instances  they  are  unusually  large;  they 
become  varicose,  nearly  to  as  great  an  extent  as  the  superficial 
ones,  and  there  is  no  doubt  that  sometimes  they  give  way,  or 
become  blocked  by  the  development  of  coagula  in  their  in- 
terior. This  naturally  causes  very  severe  pain,  owing  to  the 
way  in  which  the  nerve-fibres  are  stretched  or  compressed ;  and 
unless  absorption  is  completed  very  soon,  is  sure  to  leave  be- 
hind a  considerable  degree  of  stiffness.  The  degree  of  pain 
that  is  caused  by  the  rupture  of  a  small  vein,  especially  when 
the  extravasated  blood  is  bound  down  by  surrounding  text- 
ures, is  something-  surprising-  so  long  as  it  lasts. 

The  method  of  treatment  to  be  adopted  in  these  cases  is 
admirably  described  by  the  same  writer.  He  recommends 
that  as  soon  as  possible  after  the  accident  the  patient  should 
be  placed  in  the  recumbent  position,  with  the  injured  leg-  raised 
above  the  level  of  his  head,  and  should  be  kept  in  this  position 
for  five  minutes.  This  is  very  important  for  two  reasons.  In 
the  first  place,  the  leg-  is  emptied  at  once  of  all  superfluous 
blood,  so  that  the  swelling  soon  goes  down.  When  a  limb  is 
raised  in  this  fashion  the  artery  contracts ;  much  less  blood 
flows  to  it,  and  the  veins  are  so  rapidly  emptied  that  if  a  su- 
perficial one  has  given  way  this  alone  is  sufficient  to  stop  the 
bleeding-.  The  calf,  which  is  enlarged  and  hard,  returns  to  its 
normal  size,  and  the  patient  at  once  obtains  relief  from  the 
distressing  feeling  of  tension.  But  besides  this,  if  the  elevation 
of  the  limb  is  neglected,  the  plaster  next  to  be  described  is 


54  Sprains ;   their  Consequences  and  Treatment. 

loosened  by  the  subsidence  of  the  swelling-,  and  requires  to  be 
replaced  in  a  few  hours.  He  then  advises  that  while  the  leg- 
is  still  raised  strips  of  adhesive  plaster,  each  an  inch  and  a 
half  in  width  and  of  length  adapted  to  the  size  of  the  limb, 
should  be  applied  from  two  inches  above  the  ankle  joint  to 
above  the  thickest  part  of  the  calf,  somewhat  as  strapping-  is 
applied  in  the  treatment  of  chronic  ulcers  of  the  leg-.  As  soon 
as  it  is  applied  the  patient  should  be  directed  to  walk  about 
the  room,  and  to  place  the  heel  firmly,  or  at  least  fully,  on  the 
ground  at  each  step.  For  the  first  dozen  steps  he  will  prob- 
ably hesitate,  and  will  retain  more  or  less  of  the  limp  with 
which  he  entered ;  but  after  a  short  time,  finding-  that  his  pain 
is  diminished  or  possibly  removed,  he  will  g-ain  confidence,  and 
will  walk  with  a  pride  in  his  own  performance  which  is  very 
interesting-  to  witness.  This  description  is  exceedingly  accu- 
rate : — "  Until  this  point  is  reached  he  should  not  be  suffered 
to  depart;  for,  if  he  does  not  walk  properly  before  he  leaves 
the  surg-eon,  he  will  hesitate  still  more  when  alone,  and  will 
be  likely  to  return  to  the  ungainly  progression  which  he  ex- 
hibited at  the  commencement  of  the  interview.  Success  in 
walking-,  in  the  first  instance,  will  depend  largely  upon  the 
temperament  of  the  injured  person.  A  resolute  man,  who  be- 
lieves in  his  doctor,  will  walk  at  once,  while  a  more  timid 
patient  will  require  coaxing-  and  urging-.  The  chief  trouble 
will  be  with  the  sceptical  man,  who  has  his  own  '  views'  about 
the  injury,  and  who  will  express  them  in  such  questions  as, 
'  Well,  but  do  you  not  think  there  is  a  risk  of  inflaming  my 
leg  ? '  '  Shall  I  not  make  the  internal  wound  larger  ? '  and  so 
forth.  With  reasonable  care  neither  to  jerk  the  leg  nor  to 
twist  the  ankle  on  uneven  ground,  the  patient,  as  soon  as  the 
plaster  is  applied,  may  walk  about  as  usual.  J$y  the  third 
day  the  plaster  will  be  some\vhat  loose,  and  the  patient  will 
say  that  he  is  not  quite  so  comfortable  as  before,  and  is  less 
inclined  to  trust  his  leg.  The  strapping  should  be  reapplied, 
and  he  will  at  once  feel  more  secure  and  better  able  to  walk. 
Four  days  may  elapse  before  the  next  strapping,  which  may 
be  left  untouched  for  a  week,  but  the  application  should  be 
continued  at  intervals  until  the  patient  is  quite  convinced  of  his 
ability  to  do  without  it.  On  the  first  occasion  very  little 
pressure  is  desirable,  and  mere  laying  on  of  the  plaster  will  be 
sufficient.  Subsequent  strappings  should  be  tighter,  but  never 


Sprains ;  their  Consequences  and  Treatment.  55 

so  tight  as  to  produce  a  sense  of  unpleasant  constriction,  a 
rule  which  must  be  especially  borne  in  mind  in  applying  the 
first  and  last  piece.  The  amount  of  walking  should  be  increased 
daily,  and  after  the  third  day  the  patient  should  go  up  and 
down  stairs  freely  in  the  usual  manner.  Until  then  his  ascents 
and  descents  may  be  infantile." 

I  would  only  add  that  in  those  cases  in  which  I  believe  the 
real  cause  to  have  been  the  rupture  of  some  deep-seated  vari- 
cose vein,  I  have  found  the  above-mentioned  method  of  treat- 
ment as  successful  as  when  the  muscular  fibres  were  plainly 
torn.  In  other  parts  of  the  body  partial  rupture  is  equally 
common.  Sometimes  only  the  sheath  of  fibrous  tissue  that 
surrounds  the  muscles  gives  way;  the  soft  tissue  is  squeezed 
out  through  the  rent,  and  so  tightly  constricted  at  the  opening 
that  it  becomes  forced  into  the  shape  of  a  mushroom.  I  have 
seen  this  in  the  extensor  muscle  on  the  front  of  the  thigh.  It 
was  attributed  at  the  time  to  the  fact  that  the  patient  received 
a  violent  blow  on  the  spot  from  a  blunt  piece  of  iron  at  the 
moment  of  vigorous  contraction.  The  symptoms,  however, 
were  not  well  marked,  and  as  recovery  was  complete  without 
further  inconvenience  than  a  small  depression  in  the  substance 
of  the  muscle,  nothing  further  was  seen  of  it. 

Many  other  tendons  occasionally  give  way  during  great 
exertion.  Even  the  stoutest,  such  as  the  tendo  Achillis,  may 
be  torn  across,  though  it  is  more  common  for  the  bone  or  the 
muscle  to  yield  instead.  I  have  in  my  possession  a  shoulder 
joint  in  which  the  long  tendon  of  the  biceps  has  been  ruptured 
about  an  inch  and  a  half  from  its  attachment  to  the  bone,  so 
that  the  end  projects  into  the  cavity  of  the  joint.  The  other 
part  has  formed  for  itself  a  secondary  attachment  on  the  floor 
of  the  groove  in  which  it  normally  lies.  Similar  changes  have 
been  described  from  time  to  time  in  connection  with  many 
others. 

Dislocation  of  Tendons  and  Muscles.—  When  the  injury 
falls  short  of  actual  rupture  it  may  still  be  very  severe,  and 
lead  to  a  great  deal  of  after  trouble.  Tendons,  for  example, 
where  they  cross  a  joint  or  run  over  a  projecting  process  of 
bone,  lie  in  grooves,  which,  are  lined  with  a  delicate  sheath 
similar  to  that  in  joints,  and  this  rarely  escapes.  In  slight 
cases  it  is  merely  bruised  where  the  tendon  presses  against  it, 
but  it  may  be  filled  with  extra  va  sated  blood,  or  be  torn  open 


56  Sprains ;   their  Consequences  and  Treatment. 

down  the  whole  of  its  length,  while  the  tendon  escapes  and 
lies  displaced  among-  the  adjacent  tissues. 

In  the  Back. — Both  muscles  and  tendons  may  be  dislocated 
in  this  way.  Callender  and  others  have  shown  how  this  hap- 
pens where  long  and  slender  slips  lie  embedded  among  shorter 
and  stronger  ones,  as  in  the  back  and  some  parts  of  the  limbs. 
The  muscles  are  closely  packed  together,  surrounded,  and  at 
the  same  time  separated  from  each  other,  by  fibrous  tissue, 
which  is  dense  and  firm  toward  their  ends,  soft  and  yielding 
at  their  centre.  In  all  ordinary  movements,  carried  out  in 
an  orderly  fashion,  with  a  definite  object  in  view,  the  action 
spreads,  as  it  were,  from  one  muscle  to  the  next.  Very  few 
are  carried  out  by  the  contraction  of  a  single  one.  Nearly 
all  involve  not  only  those  immediately  necessary,  but  those 
also  by  their  side,  which  are  more  or  less  parallel  in  their 
course.  The  shape  and  consistence  alter  together,  so  that 
their  mutual  relations  remain  unchanged.  When  the  contrac- 
tion is  sudden  and  spasmodic,  it  sometimes  happens  that  one 
of  these  slips  from  its  bed  between  the  rest,  tearing  its  fibrous 
sheath,  and  becomes  displaced  or  dislocated.  Probably  this 
is  due  to  the  irregular  and  disorderly  fashion  of  the  contrac- 
tion. There  is  a  sudden  pain,  quite  local,  but  made  worse  by 
any  movement  that  would  call  that  muscle  into  play,  some- 
times so  severe  that  such  movements  cannot  be  executed  at  all. 
The  surface  of  the  skin  is  slightly  raised  if  it  is  superficial,  and 
nearly  always  there  is  considerable  local  tenderness. 

These  symptoms  are,  it  is  true,  very  nearty  the  same  as 
those  of  partial  rupture,  which  is  a  great  deal  more  common ; 
but  there  is  no  question  that  dislocation  does  sometimes  hap- 
pen, as  complete  and  almost  instantaneous  recovery  takes 
place  as  soon  as  it  is  reduced.  In  some  instances  the  patients 
have  actually  felt  the  muscle  slip  back  into  its  place  again; 
and  in  a  few  it  has  been  known  to  slip  in  and  out  again  and 
again,  owing  to  incautious  movement  at  a  too  early  period. 

The  Sartorius. — Large  muscles,  too,  are  occasionally  dis- 
placed. A  remarkable  case  has  been  recorded  in  which  the 
sartorius  was  detached  from  its  position  on  the  inner  side  of 
the  knee  by  an  accident  of  this  kind.  Just  before  its  attach- 
ment to  the  bones  of  the  leg,  this  muscle  gives  off  from  its 
border  a  tough  fibrous  expansion  to  the  capsule  of  the  joint. 
This  was  torn  across,  and  the  muscle  itself  displaced.  The 


Sprains ;  their  Consequences  and  Treatment.  57 

accident  befell  a  man  who  was  squatting  on  the  floor  of  a 
wagon  in  the  position  assumed  by  tailors.  A  companion  trip- 
ped over  him  and  fell  across  his  knees ;  something  was  felt  to 
give  way  near  the  ham,  and  on  examination  the  above  mischief 
was  made  out.  In  another  instance  under  my  own  care,  after 
a  somewhat  similar  accident,  there  was  much  tenderness,  and 
a  soft  ill-defined  swelling  over  the  inner  side  of  the  knee  for  a 
considerable  time;  and  all  the  movements  that  require  the 
assistance  of  this  muscle  were  very  painful,  as  if  some  of  its 
fibres  had  been  torn  across. 

Peroncei  Tendons. — The  tendons  of  the  peronsei  muscles, 
again,  are  not  unfrequently  displaced  from  their  position  be- 
hind the  outer  ankle.  The  sheath  that  confines  them  in  their 
groove  is  torn  down  its  whole  length,  and  they  slip  forward 
on  to  the  bone.  In  the  two  examples  that  have  come  under 
my  immediate  notice,  neither  of  the  patients  was  sufficiently 
trained  in  accurate  observation  to  give  a  reasonable  account 
of  the  way  in  which  the  accident  occurred.  It  is  not  hard, 
however,  to  conjecture  the  direction  in  which  the  foot  must 
have  been  twisted  for  such  displacement  to  be  produced.  One 
of  them  had  sprained  the  same  joint  already  several  times  be- 
fore, and  although  the  tendon  had  never  been  completely  dis- 
placed, it  is  by  no  means  improbable  that  the  constant  repeti- 
tion of  the  injury  had  caused  the  sheath  to  stretch  until  it 
became  too  weak  to  resist.  It  is  possible,  too,  that  the  groove 
in  the  bone  had  become  partly  filled  up  by  the  lymph  thrown 
out.  In  neither  was  there  the  least  difficulty  in  reduction ;  but 
while  this  was  successful  and  permanent  in  the  case  of  the 
one,  in  the  other  the  least  movement  caused  them  to  slip  over 
the  bony  margin  again,  confirming  my  suspicion  that  the  mis- 
chief was  not  due  to  one  accident  only.  Bandaging,  strap- 
ping with  pads  in  all  positions,  fixed  apparatus  of  many  kinds, 
complete  rest,  with  the  foot  kept  at  a  right  angle  for  weeks 
together,  all  were  of  no  service.  Gradually  the  inconvenience 
became  so  much  less  that  the  patient  would  not  submit  to  any 
further  treatment.  At  first,  each  time  they  slipped  forward 
there  was  the  peculiar  sickening  pain  common  to  all  over- 
stretched fibrous  textures;  but  soon  this,  too,  ceased  to  be  felt, 
and  the  patient  having  had  no  arch  to  his  foot  for  some  long 
time  before,  the  comparative  loss  of  these  muscles  was  not  so 
serious  to  him  as  it  otherwise  would  have  been. 


58  Sprains ;  their  Consequences  and  Treatment. 

On  the  Hand,  etc. — Other  tendons  do  not  so  often  suffer  in 
this  way.  Paget  has  described  displacement  of  some  of  the 
extensor  ones  on  the  back  of  the  wrist;  but  though  a  slight 
degree  of  slipping  and  yielding  at  this  point  is  very  common, 
complete  dislocation  rarely  happens,  probably  because  the 
direction  in  which  they  run  deviates  so  little  from  the  straight 
line.  In  bad  cases  of  knock-knee,  the  knee-cap  lying  in  the 
tendon  of  the  great  extensor  often  slips  to  the  outer  side  of 
the  joint  when  the  limb  is  straightened;  and  the  same  thing 
sometimes  occurs  during  flexion,  from  defective  development 
of  the  lower  limb,  associated  with  a  peculiar  kind  of  deformity; 
but  neither  of  these  can  be  fairly  regarded  as  dislocation  of  a 
tendon  due  to  injury 

Biceps. — Whether  the  long  tendon  of  the  biceps  can  be 
displaced  from  the  groove  in  which  it  lies  seems  still  not  quite 
certain.  I  have  seen  one  case  in  which  this  peculiar  injury  was 
diagnosed,  and  although  verification  was  not  possible,  I  think 
there  can  be  no  doubt  not  only  that  the  tendon  did  actually 
slip  out  of  its  bed,  but  that  by  twisting  the  arm  round,  which 
the  patient  could  do  by  means  of  his  other  hand,  it  could  be 
made  to  slip  in  and  out  again  at  pleasure.  No  snap  could  be 
heard,  it  is  true,  nor  was  there  any  distinct  difference  along 
the  front  of  the  arm  when  the  two  sides  were  compared  to- 
gether; but  the  inability  to  raise  the  arm  from  the  side  at 
one  moment,  and  the  comparatively  free  range  of  action  after 
reduction  had  been  effected,  left  little  doubt  that  it  was  a 
genuine  example.  Passive  motion  was  fairly  good,  as  it  was 
in  the  case  described  by  Hamilton,  only  somewhat  painful. 
There  was  no  undue  prominence  on  the  front  of  the  shoulder, 
possibly  because  of  the  recent  date  of  the  accident.  The  case, 
it  is  admitted,  is  incomplete,  and  as  the  patient  was  under  my 
observation  only  a  short  time,  I  cannot  give  any  account  of 
the  subsequent  progress.  It  does  not  agree  in  all  respects 
with  those  recorded;  but  as  Hamilton  has  shown  by  actual 
dissection  the  possibility  of  such  an  accident,  and  as  I  cannot 
understand  what  other  displacement  in  the  region  of  the 
shoulder  could  have  produced  so  peculiar  a  train  of  symptoms, 
sometimes  well  marked  and  definite,  and  then  all  of  a  sudden 
disappearing  for  a  time,  I  think  it  must  be  allowed.  In  old 
cases  of  rheumatic  gout  it  is  not  at  all  uncommon  to  find  the 
groove  filled  up,  and  the  tendon  flattened  out  over  some  ad- 


Sprains ;   their  Consequences  and  Treatment.  59 

jacent  part  of  the  head  of  the  bone,  but  there  was  no  evidence 
of  disease  in  the  present  instance. 

Ruptured  Veins. — The  presence  of  varicose  veins  is  often 
a  serious  matter  when  the  ankle  joint  is  sprained,  particularly 
in  the  case  of  a  person  who  is  advanced  in  life ;  and  in  this  re- 
spect minute  vessels^  which  give  rise  merely  to  a  mottled 
bluish  appearance  of  the  skin,  are,  perhaps,  more  to  be  appre- 
hended than  when  one  or  two  of  the  larger  trunks  only  are 
involved.  The  actual  amount  of  blood  lost  may  not  be  so 
great,  but  the  tissues  do  not  seem  so  well  nourished,  and  ab- 
sorption is  much  more  slow.  It  must  not  be  forgotten  either 
that  the  deep  intermuscular  veins  are  often  as  much  dilated 
as  the  more  superficial  ones,  and  that  when  they  give  way  a 
very  large  quantity  of  blood  may  be  effused  into  the  deeper 
strata  of  a  limb  before  making  its  appearance  on  the  surface. 
The  inconvenience  that  results  from  this  is  very  serious,  and 
convalescence  is  much  protracted ;  for  until  the  whole  of  the 
blood  thus  effused  is  absorbed  the  muscles  do  not  recover  their 
freedom  of  action,  or  the  subcutaneous  tissues  their  normal 
supple  feel.  Rigidity  and  oedema,  worse  when  any  exertion  is 
made,  may  persist  for  months  solely  owing  to  this. 

Injury  to  Bones. — This  even  does  not  exhaust  the  list  of 
structures  that  may  be  injured.  The  bones  themselves  are 
frequently  bruised,  especially  when,  either  from  delicacj7  of 
constitution  or  other  causes,  such  as  disease,  their  substance 
is  soft  and  vascular  with  an  undue  amount  of  fat  in  their  com- 
position. It  is  true  these  injuries  are  not  often  demonstrated, 
though  I  have  sometimes  found  dark  stains,  due  to  hemor- 
rhage, deep  in  their  substance;  but  inflammation  is  sufficiently 
common  to  make  it  unreasonable  to  doubt  that  they  too  meet 
with  their  share  of  damage.  Diseases  of  the  spine,  hip,  and 
other  joints  in  children  may  be  due,  in  great  measure,  to  some 
constitutional  taint,  though  it  is  open  to  question  whether  the 
influence  of  this  is  not  overrated ;  but  it  is  quite  c.ertain  that 
the  immediate  starting-point  in  nine  cases  out  of  ten  is  some 
chance  sprain,  often  so  slight  as  scarcely  to  have  been  noticed 
at  the  time. 


CHAPTER  V. 

INFLAMMATION  AND  THE  PROCESS  OF  REPAIR. 

THE  changes  that  take  place  in  the  tissues  after  the  imme- 
diate effects  of  the  injury  have  disappeared  cannot  be  allowed 
to  pass  without  some  degree  of  notice.  It  is  true  that  there 
is  little  that  is  special  or  peculiar  about  them ;  they  are  in 
nearly  all  respects  identical  with  those  that  follow  fractures 
or  other  injuries;  but,  for  some  reason  or  other,  it  is  the  popu- 
lar impression,  one  that  is  shared,  too,  by  not  a  few  medical 
men,  that  these  accidents  are  almost  invariably  followed  by 
acute  inflammation.  Imperfect  recovery  is,  I  admit,  exceed- 
ingly common ;  it  is  the  frequency  of  it  which  makes  sprains 
so  serious;  but,  rightly  or  wrongly,  inflammation  is  nearly 
always  regarded  as  the  cause.  If  it  is  the  case,  it  is  only 
reasonable  that  it  should  be  allowed  a  certain  amount  of  in- 
fluence on  the  kind  of  treatment  adopted. 

At  first  sight,  I  am  bound  to  confess,  much  apparently  may 
be  said  in  favor  of  this  opinion.  There  is  nearly  always  pres- 
ent in  these  cases  a  cavity  of  some  kind  or  other,  whether  it 
is  a  joint,  sac,  bursa,  or  tendon  sheath;  and  this  is  certain  to 
be  distended  under  considerable  pressure  by  blood  or  lymph, 
which,  unless  active  measures  are  taken,  is  very  slowly  re- 
moved by  absorption.  The  quantity  that  may  collect  in  a  few 
minutes  is  enormous ;  I  have  on  many  occasions  seen  the  wrist 
double  the  circumference  of  its  fellow  within  half  an  hour  of 
an  accident.  Naturally  the  degree  of  tension  is  very  consider- 
able; the  sensory  nerves  are  stretched  or  compressed;  the 
part  begins  to  throb ;  the  skin  becomes  hot  and  red ;  and,  to 
all  appearance,  there  is  the  commencement  of  an  attack  of 
acute  inflammation. 

Now,  there  is  no  question  that  if  this  is  allowed  to  continue 
unchecked  it  is  very  likely  to  be  followed  by  this  result ;  but 
if  due  and  proper  precautions  are  taken  against  it  there  need 


Sprains ;  their  Consequences  and  Treatment.  61 

not  be  the  least  fear.  When  inflammation  breaks  out,  it  is 
either  the  consequence  of  neglect,  maltreatment,  or  some  pecul- 
iarity of  constitution,  such  as  gout  or  struma,  so  marked  that 
the  least  accident  is  sufficient  to  precipitate  an  attack.  The 
changes  that  take  place  in  the  tissues  after  sprains  are  merely 
those  necessary  for  the  repair  of  the  damage ;  it  is  only  when 
they  are  encouraged  beyond  measure  by  other  causes  that 
inflammation  is  likely  to  break  out. 

Hypercemia  and  Softening. — As  soon  as  the  bleeding-  is 
checked  the  vessels  all  through  the  injured  area  dilate,  and 
their  walls  become  relaxed  and  softened.  The  volume  of  blood 
circulating1  through  the  part  is  immensely  increased ;  a  much 
larger  amount  of  liquid  plasma  pours  out  through  the  walls 
into  the  tissues  round,  mixing  with  the  blood  that  has  already 
been  extra vasated.  All  the  interstices  are  filled  with  it,  and 
become  distended  more  and  more,  until  the  joint  swells  up  and 
the  skin  becomes  tense  and  shining  from  the  way  in  which  it 
is  stretched.  The  ditferent  tissues  are  affected,  of  course,  in 
different  degrees ;  the  capsule  itself,  owing  to  its  delicate  con- 
struction, very  soon  becomes  thickened  and  softened;  the  loose 
tissue  round  it  is  affected  even  more  quickly;  the  ligaments, 
from  the  way  in  which  their  fibres  lie  close  set  against  each 
other,  resist  much  longer;  but  they,  too,  at  length,  if  the 
process  continues  unchecked,  undergo  a  similar  change,  so 
that  the  softening  and  distention  become  general. 

Effusion  and  Distention. — The  fluid  pours  at  once  into 
any  natural  spaces,  such  as  tendon  sheaths  or  bursse,  that 
may  be  present.  These  and  the  synovial  sacs  of  joints  are  the 
first  to  become  distended,  so  that  for  some  time  the  shape  of 
the  swelling  follows  distantly  the  natural  contour  of  the  part. 
Later,  \vhen  the  connective  tissue  round  becomes  softened  and 
the  swelling  more  general,  this  is  lost,  and  the  outline  is 
rounded  and  uniform.  At  this  stage  the  skin  may  be  whiter 
than  natural,  though  the  temperature  when  the  hand  is  laid 
upon  it  is  higher  than  that  of  the  corresponding  point  of  the 
opposite  limb ;  the  superficial  parts  are  so  tensely  stretched 
that  the  blood-vessels  are  emptied  by  the  pressure,  but  the 
sensation  of  warmth  is  still  transmitted  from  below. 

Very  little  of  this,  of  course,  is  to  be  seen  post-mortem. 
No  hyperaemia  can  be  found  then,  no  matter  how  great  it  was 
during  life.  It  disappears  with  the  vitality  of  the  part,  and 


62  Sprains ;  their  Consequences  and  Treatment. 

its  extent  and  degree  can  only  be  conjectured  from  the  few 
signs  it  leaves  behind.  Minute  extravasations  may  be  found 
here  and  there,  especially  among  the  softer  parts;  and  the 
fluid  in  the  cavities  may  be  stained  with  blood  in  different  de- 
grees, or,  it  may  be,  turbid  from  shreds,  and  flakes  of  fibrin  or 
mucus  floating-  in  it;  but  apart  from  the  actual  lacerations, 
nothing  further  can  be  seen  in  the  earliest  stages. 

At  a  later  period  the  changes  are  better  marked.  The 
smooth  glistening  polish  on  the  inner  lining  of  the  joint  is 
gone;  in  its  place  there  is  a  dull  and  lustreless  surface,  stained 
and  discolored  by  the  blood,  and  coated  over  with  a  deposit 
similar  to  that  which  makes  the  fluid  in  the  interior  turbid. 
In  recent  cases  this  may  be  washed  off;  after  a  time  it  appears 
to  be  incorporated  with  the  wall  itself.  The  two  cannot  be 
separated,  and  if  a  small  portion  is  removed  and  examined 
under  water,  a  number  of  little  gelatinous  processes  float  up 
from  the  surface,  so  that  it  looks  something  like  a  piece  of 
coarse  velvet.  This  is  particularly  marked  over  the  softer 
parts  of  the  capsule,  where  the  sy  no  vial  membrane  is  thrown 
into  folds,  or  where  masses  of  delicate  and  vascular  connective 
tissue  project  into  the  interior  for  the  pupose  of  filling  up  the 
irregularities  between  the  bones.  On  the  other  hand,  where 
the  ligaments  directly  bound  the  cavity,  merely  covered  by  a 
layer  of  cells,  with  no  soft  intervening  stratum,  hardly  any 
such  change  is  to  be  seen.  So  it  is  with  the  cartilage  that 
covers  the  bones;  it  scarcely  shows  a  trace;  even  the  blood 
stains  cannot  penetrate  beneath  the  surface. 

Organization. — The  softer  and  looser  the  tissue  the  greater 
the  effect.  Round  the  edge  of  the  joints,  sp  to  speak,  outside 
the  line  of  pressure,  where  the  fibrous  capsule  is  attached  to 
the  bones,  and  where  the  synovia!  membrane  lies  folded  on 
itself,  and,  as  age  advances,  becomes  covered  over  with  fringes 
and  villous  processes,  the  bruising  and  softening  are  most 
conspicuous.  It  is  not  the  surface,  or  the  lining  membrane 
only,  that  shows  the  change ;  the  whole  thickness  of  the  cap- 
sule is  affected,  and  where  it  is  thin  and  delicate,  or  where, 
owing  to  the  shape  of  the  bones,  there  are  hollow  spaces  round 
on  which  pressure  never  falls,  the  tissues  outside  suffer  too. 
In  more  than  one  example  I  have  seen  this  extend  long  dis- 
tances by  the  side  of  the  bones;  and  it  is,  I  believe,  in  great 
measure  owing  to  this  that  many  sprains,  apparently  trivial 


Sprains;  their  Consequences  and  Treatment.  63 

at  the  outset,  are  followed  by  such  impairment  of  mobility. 
Unless  measures  are  taken  to  prevent  it,  the  whole  of  the 
fibrous  structures  at  this  part,  the  folds  of  the  synovia!  mem- 
brane, the  capsule,  and  the  loose  tissue  outside  it,  appear  to  be 
lost  in  a  soft,  gelatinous  mass  of  lymph,  in  which  a  few  fibres 
here  and  there  can  still  be  found.  If  the  joint  is  allowed  to 
remain  unmoved  this  fills  up  the  entire  hollow  between  the 
bones.  Then,  after  the  effect  of  the  injury  has  passed  off,  when 
the  hypersemic  stage  is  becoming-  less  marked  and  repair  is 
carried  on  more  actively,  it  becomes  organized,  and  converted 
into  dense,  unyielding,  fibrous  tissue,  which  ties  the  bones  to- 
gether, and  to  a  great  extent  cripples  the  joint.  It  is  not  the 
fault  of  the  synovia!  membrane  alone,  or  the  capsule,  or  the 
soft  and  loose  connective  tissue  on  the  outside ;  they  all  play 
their  part,  though  the  share  each  of  them  takes  may  show  a 
certain  degree  of  difference  in  different  cases. 

In  Joints. — In  the  shoulder,  for  example,  stiffness  of  this 
description  is  of  common  occurrence,  and  may  lead  to  serious 
inconvenience.  At  the  lower  and  inner  part  of  the  joint  the 
capsule  is  very  thin,  and  has  round  it  a  large  amount  of  loose 
fibrous  tissue,  so  soft  and  delicate  that  it  is  thrown  into  folds 
when  the  arm  is  hanging  by  the  side.  No  pressure  falls  on  it 
so  long  as  the  limb  is  in  the  natural  position ;  as  it  is  raised 
from  the  side  the  folds  are  gradually  straightened  out,  until 
they  are  put  upon  the  stretch  by  the  pressure  of  the  head  of 
the  bone.  Now,  when  the  joint  is  sprained  or  hurt,  this  part 
of  the  capsule,  owing  to  its  softness  and  vascularity,is  exceed- 
ingly likely  to  be  injured;  and  unless  active  measures  are  taken 
to  prevent  it,  the  whole  of  it  is  very  easily  converted,  first  into 
a  mass  of  soft,  vascular  lymph,  and  then  into  dense  and  un- 
yielding fibrous  tissue.  There  is  nothing  to  prevent  it.  There 
is  no  pressure  to  close  the  vessels  and  limit  the  amount  of 
lymph  thrown  out,  or  to  help  on  the  process  of  absorption; 
the  folds  are  never  opened  out  or  separated  from  each  other; 
if  the  joint  is  in  the  least  degree  painful  it  is  kept  at  perfect 
rest,  owing  to  the  presence  of  others  close  by  ready  to  under- 
take its  work,  and  all  the  time  without  the  patient  being  aware 
of  it.  When  he  is  directed  to  raise  his  arm  sideways  from  the 
body,  he  imagines  he  is  using  his  shoulder  joint,  while,  as  a 
matter  of  fact,  the  whole  of  the  action  is  being  carried  out  by 
others ;  and  this  goes  on  until,  by  degrees,  organization  com- 


64  Sprains ;  their  Consequences  and  Treatment. 

mences,  and  the  part  quietly  becomes  stiff  and  rig-id.  The  sur- 
faces of  the  folds  become  adherent  to  each  other,  and  incor- 
porated with  the  tissue  round;  and  instead  of  a  soft  and  flexi- 
ble capsule,  there  is  a  mass  of  shortened,  rigid,  and  unyielding- 
fibrous  tissue,  matting1  everything  together,  and  not  only  by 
its  strength  preventing  proper  movement  of  the  bones,  but, 
by  the  pain  it  causes  when  any  attempt  is  made,  preventing 
any  vigor  being  thrown  into  it. 

Between  Muscles. — Similar  changes  take  place  in  the 
planes  of  the  soft,  cellular  tissues  that  surround  muscles,  lying 
between  them  and  other  structures.  The  blood,  escaping  into 
these  from  the  torn  vessels,  makes  its  way  along  the  line  of 
least  resistance  until  it  reaches  some  part  where  there  is  no 
pressure  or  movement.  Here  it  remains,  passive  and  un- 
changed, for  a  considerable  period ;  but  at  length  it  slowly  be- 
comes organized,  and  by  gluing  together  the  different  strata, 
gives  rise  to  the  stiffness  and  loss  of  power  that  are  so  com- 
mon after  severe  muscular  strains. 

In  Bursce. — The  effect  produced  by  large  bursae  has  been 
already  mentioned  in  speaking  of  joints.  Many  of  them  are 
merely  open  spaces  in  the  connective  tissue,  lined  by  a  single 
layer  of  cells,  and,  in  ordinary  circumstances,  contain  merely 
sufficient  fluid  to  enable  one  surface  to  glide  freely  and  smoothly 
on  another.  In  reality  they  are  formed,  as  required,  out  of 
the  intercellular  and  interfibrillar  spaces  that  exist  everywhere 
in  connective  tissue.  After  sprains  they  act  as  receptacles 
for  blood  and  lymph,  and  often  become  immensely  distended. 
If  the  fluid  is  quickly  absorbed  again  there  is  no  ill  result ;  the 
walls  contract,  and  -the  cavity  resumes  its  former  size  and 
shape ;  but  if  there  is  any  delay  when  at  length  absorption 
does  take  place,  the  softened  and  relaxed  walls  are  thrown 
into  folds,  so  that  the  sides  grow  together  and  become  incor- 
porated with  each  other.  Instead  of  there  being  a  thin-walled 
sac,  assisting  every  movement  by  diminishing  friction,  there 
is  a  rigid  mass  of  tissue,  stiffened,  irregularly  thickened,  and 
adhering  to  everything  round  it,  the  seat  of  constant  pain  and 
tenderness.  "When  this  change  is  established,  restoration  is 
much  delayed.  The  progress  at  first  is  often  rapid,  the  later 
stages  are  sure  to  lag  behind ;  and  the  longer  the  thickening1 
and  infiltration  of  the  tissues  have  lasted,  the  greater  difficulty 
there  is  in  getting  rid  of  them. 


Sprains ;  their  Conseqiiences  and  Treatment.  65 

Inflammation. — These  changes  are  not  due  to  inflamma- 
tion. Pilcher,  in  describing  the  consequences  of  sprains  affect- 
ing- the  wrist  joint,  has  shown  the  difference  between  them 
with  admirable  clearness.  It  is  perfectly  true  that  the  parts 
are  swollen  from  the  extravasation  of  blood,  and  the  effusion 
of  lymph ;  that  the  skin  is  sometimes  reddened,  and  the  tem- 
perature raised,  owing  to  the  increased  amount  of  blood  circu- 
lating in  the  vessels  of  the  injured  area;  and  that  there  is 
tenderness  and  pain,  partly  because  the  nerves  are  torn  across, 
partly  because  the  sensitiveness  of  the  skin  is  heightened;  but 
this,  though  it  may  end  in  it,  does  not  make  up  inflammation. 

The  increase  in  the  flow  of  blood  is  the  natural  outcome  of 
the  injury.  A  certain  amount  of  repair  is  always  being  carried 
on,  in  correspondence  with  the  ordinary  wear  and  tear  of 
everyday  life.  At  times,  from  accidents  or  other  causes,  this 
work  undergoes  an  immense  increase ;  then,  in  accordance  with 
the  physiological  laws  which  control  all  parts  of  the  body,  a 
much  larger  amount  of  blood  flows  through  the  part,  and  a 
greater  quantity  of  reparative  lymph  is  poured  into  it. 

So  long  as  the  skin  remains  unbroken,  it  is  altogether  un- 
usual for  injured  parts  to  become  inflamed.  Except  under 
such  circumstances  as  blood-poisoning  (when  any  injury  leads 
to  abscess),  or  where  from  some  accidental  cause,  such  as  the 
rupture  of  a  large  artery,  a  high  degree  of  tension  is  set  up  in 
the  tissues,  inflammation  following  a  subcutaneous  injury  is 
the  exception,  not  the  rule.  Fractured  bones,  when  the  skin 
is  unbroken,  hardly  ever  excite  inflammation;  contusions  and 
bruises  may  more  often,  because  it  is  more  common  in  them  to 
meet  with  tension  from  fluid  that  is  allowed  to  accumulate ; 
sprains  form  no  exception.  Inflammation  may  set  in  from 
maltreatment  or  neglect ;  from  peculiar  conditions  of  the  blood 
(such  as  gout  or  rheumatism)  in  which  inflammation  of  joints 
sometimes  occurs  without  any  injury  at  all;  or  if  a  large 
amount  of  blood  is  allowed  to  accumulate,  just  as  it  sometimes 
does  after  a  bruise;  but  under  ordinary  conditions  it  is  not  a 
necessary  consequence,  and  may  nearly  always  be  prevented. 

This  is  of  material  importance  in  the  question  of  treatment. 
As  regards  the  time  at  which  this  should  be  commenced,  most 
people  are  agreed ;  and  the  methods  adopted  for  the  earliest 
stage  have  (most  of  them)  something  to  be  said  on  their  be- 
half; but  when  the  second  stage  is  reached,  as  Pilcher,  Hood, 


66  Sprains ;  their  Consequences  and  Treatment. 

and  many  others  have  pointed  out,  the  mistaken  notion  of  in- 
flammation being-  a  necessary  consequence,  has  given  rise  to 
a  plan  which  is  not  only  directly  opposed  to  all  that  is  rational, 
but  which,  as  mig-ht  be  expected  of  anything-  of  which  such  a 
statement  can  be  made,  is  to  be  reg-arded  as  the  immediate 
cause  of  many  of  the  troubles  of  later  times.  Small  blood- 
vessels are  always  torn  across  when  such  accidents  happen; 
sometimes  the  number  is  considerable;  a  certain  amount  of 
extravasation  necessarily  follows;  this  must  be  absorbed,  and 
the  injured  tissues  repaired  or  replaced,  before  the  part  can 
be  said  to  have  recovered,  but  it  is  always  effected  by  perfectly 
natural  means.  The  amount  of  blood  that  circulates  through 
the  part,  and  the  quantity  of  lymph  that  is  poured  into  the 
tissues,  are  increased  in  proportion  to  the  work  that  has  to  be 
done.  The  softening  of  the  intercellular  substance  is  to  facili- 
tate this.  It  is  only  when  the  process  passes  beyond  what  is 
needed  for  the  purpose,  and  becomes  continuous  and  progres- 
sive, that  it  deserves  the  name  of  inflammation. 

It  does  not  do,  however,  on  this  account  to  run  to  the  other 
extreme,  and  declare  that  inflammation  never  occurs.  If  a 
larg-e  amount  of  blood  escapes  from  the  vessels  into  the  tissues, 
or  if  from  using-  the  joint  too  freely  or  too  soon  after  it  has 
been  hurt,  the  hyperasmia  is  not  allowed  to  subside,  it  is  almost 
certain  to  do  so.  Anything-  that  causes  a  high  degree  of  ten- 
sion is  sufficient  to  induce  it;  the  part  begins  to  throb;  the 
temperature  rises;  the  swelling-  increases  more  and  more  until 
it  may  declare  itself  at  any  moment.  It  is  more  likely  to 
break  out  in  certain  constitutions,  and  in  certain  joints;  but  if 
any  synovial  sac,  or  bursal  space,  is  allowed  to  become  dis- 
tended, it  follows  as  naturally  as  it  does  elsewhere.  Only,  so 
long-  as  the  amount  of  effusion  is  confined  within  due  limits, 
so  that  the  tissues  can  deal  with  it  with  a  little  assistance, 
without  being-  overtaxed,  inflammation  is  the  exception,  always 
provided  there  is  no  constitutional  predisposition  to  bring  it 
on. 

Absorption. — These  are  the  chang-es  that  take  place  in  one 
direction.  Side  by  side  with  them,  commencing-  more  slowly, 
it  is  true,  but  steadily  progressing-  until  it  gains  upon,  and 
finally  overtakes  them,  is  the  process  of  absorption.  The 
sooner  it  begins,  and  the  greater  the  activity  with  which  it  is 
carried  on,  the  better  the  prospect  of  speedy  recovery.  When 


Sprains ;  their  Consequences  and  Treatment.  67 

it  is  incomplete,  the  consequences  are  always  serious.  As 
already  mentioned,  inflammation  may  set  in  and  end  in  grave 
disease;  the  synovial  cavity  of  the  joint  may  continue  dis- 
tended with  fluid  until  the  capsule  loses  its  elasticity  and  can- 
not contract  again ;  the  ligaments  may  be  stretched  and  soft- 
ened; there  may  be  hard,  unyielding  masses  of  old  blood  clot 
lying  among  the  tissues,  and  causing  pain  by  pressing  upon 
the  nerves;  or  bands  of  lymph,  converted  into  fibrous  tissue, 
may  pass  from  one  bone  to  the  other  across  the  joint,  making 
it  stiff  and  rigid,  and  preventing  free  movement.  Sometimes 
(after  a  sprained  ankle,  for  instance)  the  soft  tissues  behind 
the  bony  prominences  remain  swollen  and  puffy  for  years,  get- 
ting better  from  time  to  time,  and  then,  again,  especially  of 
an  evening  or  after  any  exertion,  swelling  up  more  than  ever. 
At  others,  the  nutrition  of  the  part  does  not  recover,  and  it 
remains  cold  and  stiff,  with  a  look  of  utter  helplessness  about 
it.  Whenever,  in  short,  recovery  after  a  sprain  is  incomplete, 
and  no  actual  displacement  or  other  gross  lesion  can  be  found 
to  account  for  it,  the  real  fault  is  that  absorption  has  never 
been  thoroughly  carried  out,  and  that  the  circulation  is  not 
restored.  The  perfect  recovery  after  these  injuries  is,  however, 
of  so  much  importance,  and  is  so  intimately  bound  up  with 
the  question  of  treatment,  that  it  must  be  dealt  with  by  itself. 
The  track  of  the  extravasated  blood,  as  it  is  absorbed,  is 
easily  made  out.  The  red  blood  corpuscles  break  down,  and 
are  destroyed ;  their  coloring  matter  dissolves  in  the  fluid,  and 
soaks  into  the  tissues  along  the  easiest  routes,  marking  its 
path  by  the  staining  of  the  skin.  The  distance  this  spreads, 
and  the  length  of  time  it  lasts,  maj^  give  some  idea  of  the 
slowness  with  which  absorption  is  carried  on,  even  when  the 
area  is  extensive.  It  is  no  uncommon  thing  for  the  bruising 
of  a  sprained  ankle  to  reach  the  knee;  and  it  may  be  many 
weeks  before  the  last  trace  has  vanished.  Even  then  it  dis- 
appears from  the  connective  tissue  interspaces  outside  the 
joint  more  rapidly  than  it  does  from  the  synovial  sac  within, 
or  the  bursae  and  tendon  sheaths  round.  In  the  one  case  it  is 
widely  diffused  among  the  fibres,  lying  actually  in  the  little 
interstitial  spaces,  out  of  which  the  absorbent  vessels  spring; 
in  the  other  it  occupies  a  cavity,  only  part  of  the  wall  of  which 
possesses  any  absorbing  power,  and  that  not  in  a  very  high 
degree.  Sometimes,  owing  to  this,  a  few  days  after  a  sprain, 


68  Sprains ;  their  Consequences  and  Treatment. 

the  joint  appears  larger  in  proportion  to  the  parts  round  than 
it  did  shortly  after  the  injury. 

Gradually  the  semi-fluid  material  between  the  cells  and 
fibres  diminishes  in  amount,  and  becomes  firmer  in  consistence ; 
the  surplus  lymph,  not  needed  for  the  repair  of  the  tissues,  is 
carried  off,  taking  with  it  the  remaining  debris  of  the  red 
blood  corpuscles;  and  the  nutritive  plasma  circulates  again  in 
normal  amount,  and  at  its  normal  rate,  through  the  tissues. 

Effects  of  Pressure. — It  is  worth  noting  how  immensely 
these  changes  are  assisted  by  the  judicious  use  of  compression. 
The  extra vasated  blood  betrays  its  presence  everywhere  by 
the  stains  upon  the  skin.  In  nearly  every  case  it  follows  defi- 
nite directions,  being  guided  along  certain  strata  either  by  the 
arrangement  of  the  stronger  sheets  of  fibrous  tissue  which 
surround  and  separate  groups  of  muscles,  or  else  by  pressure 
applied  from  the  outside.  Where  the  bones  lie  immediately 
under  the  surface,  so  that  the  skin  and  subcutaneous  tissues 
are  firmly  compressed  when  a  bandage  is  applied,  the  color 
remains  white  and  unstained.  In  the  hollows  between  the 
bones,  or  behind  eminences,  which  protect  the  soft  parts,  the 
tissues  are  swollen  and  puffed  out,  and  may  be  jet  black  for  a 
time.  So  it  is  with  the  effusion  of  lymph  at  a  later  period ; 
only  owing  to  there  being  here  no  alteration  of  color,  the  signs. 
are  not  so  conspicuous.  The  swelling  always  disappears  first 
from  those  parts  on  which  the  pressure  falls ;  it  persists  long- 
est in  just  those  places  where  it  effects  most  mischief,  in  the 
little  irregular  hollows  that  lie  between  the  bones,  especially,, 
as  has  been  mentioned  already,  in  the  case  of  the  shoulder,  on 
the  side  where  the  tissues  are  softest  and  most  yielding. 

As  the  tissues  shrink  to  their  former  size,  the  lining  mem- 
brane of  the  joint  cavity  slowly  resumes  its  natural  appear- 
ance. Granulations  cease  to  form  on  the  inner  surface;  the 
latest  formed  cells,  instead  of  dropping  off  into  the  fluid,  be- 
come firmer  and  flatter,  and  are  held  together  better  by  the 
cementing  substance,  so  that  they  reproduce  the  glistening 
surface  of  the  synovial  lining.  The  fluid  becomes  more  clear 
again,  and  its  normal  color  and  consistence  return,  though  the 
quantity  may  continue  excessive  for  a  very  considerable  time. 

Permanent  Changes. — The  fringes,  and  the  tissues  at  their 
base,  retain  their  altered  character  the  longest.  Often,  indeed, 
they  never  quite  regain  their  farmer  size  or  texture.  They 


Sprains ;  their  Consequences  and  Treatment.  69 

become  firm  and  hard,  and  more  opaque  from  the  organiza- 
tion of  lymph  in  their  substance.  Sometimes  the  larger  ones 
become  vascular,  a  loop  of  blood-vessels  growing1  down  into 
them  from  the  base ;  and  then  they  are  practically  permanent. 
If  a  joint  has  been  sprained  more  than  once,  their  presence  can 
nearly  always  be  detected  in  certain  favorite  localities,  as,  for 
example,  on  either  side  of  the  knee-cap.  Owing  to  the  synovial 
membrane  being  so  superficial  here  they  can  be  felt  quite  dis- 
tinctly, even  when  they  are  still  small,  rolling  between  the 
finger  and  the  bone.  So  long  as  they  remain  small  they 
scarcely  give  rise  to  a  sensation  of  inconvenience,  but  when 
they  reach  any  size  they  act  to  all  intents  and  purposes  as  so 
many  fixed  foreign  bodies.  Owing  to  their  position,  well  out 
of  the  way  of  the  bones,  they  do  not  often  get  caught  between 
them,  or  they  would  prove  a  grave  source  of  danger;  but  even 
though  they  escape  this,  they  keep  up  a  continuous  if  slight 
amount  of  irritation;  the  hyperaemia  and  effusion  never  quite 
disappear;  the  capsule  and  the  ligaments  become  involved 
more  and  more,  and  the  strength  and  security  of  the  joint  at 
length  are  seriously  impaired. 

Length  of  Time. — Where  ligaments  have  been  torn,whether 
they  are  completely  separated  in  two,  or,  what  is  more  usual, 
have  merely  sustained  a  number  of  small  lacerations  in  their 
substance,  it  is,  of  course,  a  matter  of  some  considerable  time 
before  perfect  repair  can  be  effected.  So  it  is  when  muscles  or 
tendons  are  torn,  or  if  the  sheath  in  which  they  lie  is  widely 
rent ;  and  above  all,  if,  before  the  parts  are  firmly  united  an- 
other undue  strain  falls  on  them.  When  this  occurs,  not  only 
is  the  whole  of  the  original  mischief  reproduced,  but  the  de- 
gree is,  generally  speaking,  more  severe;  for,  owing  to  the 
vascularity  and  softness  of  the  part  at  the  time,  the  haemor- 
rhage and  laceration  are  nearly  always  more  extensive  than 
they  were  at  first. 

It  is  impossible  to  lay  down  any  precise  rule  as  to  the  length 
of  time  required  for  the  repair  of  these  more  serious  hurts. 
Each  case  must  be  judged  on  its  own  merits.  The  amount  of 
injury,  not  merely  that  sustained  at  the  moment,  but  the  sub- 
sequent damage  often  inflicted  in  ill-advised  attempts  at  treat- 
ment; the  kind  of  tissue  that  has  suffered  most;  the  extent  of 
the  extravasation;  the  particular  kind  of  joint,  whether  in  the 
upper  or  the  lower  limb ;  the  age,  and  above  all,  the  constitu- 


70  Sprains ;  t/ncir  Consequences  and  Treatment. 

tion  of  the  patient ;  the  care  he  will  take  of  himself ;  all  these 
things  have  to  be  considered  with  many  others  before  an  esti- 
mate can  be  given.  All  that  can  be  said  is  that  a  severe  sprain, 
tearing  a  strong  ligament,  or  wrenching  it  from  the  bone,  takes 
quite  as  long  before  union  is  perfect  as  a  fracture  through  the 
bone  near  it.  The  patient  may  be  able,  probably  will  be  able, 
to  make  limited  use  of  the  limb  much  earlier,  especially  if  he 
is  careful  to  avoid  any  movement  calculated  to  throw  a  strain 
on  the  injured  part  (which,  of  course,  in  the  case  of  a  fracture 
is  rarely  possible) ;  but  recovery  takes  at  least  as  long,  and 
perfect  convalescence,  with  perfect  movement,  often  much 
longer. 


CHAPTER  VI. 

IMPERFECT     RECOVERY. 

ONE  of  the  most  annoying-  things  in  connection  with  sprains 
is  the  frequency  with  which  they  improve  up  to  a  certain  point 
and  then  come  to  an  abrupt  standstill.  It  is  not  merely  that 
convalescence  is  protracted,  it  is  delayed  so  long-  that  it  be- 
comes a  question  if  the  joint  is  ever  to  recover.  For  the  first 
few  days,  perhaps,  everything  progresses  as  well  as  it  possibly 
can.  The  patient  is  wise  enough  to  recognize  the  situation, 
and  to  reconcile  himself  to  the  necessary  confinement,  though 
this,  as  only  those  who  have  suffered  themselves  know,  is  very 
often  far  from  being  an  easy  matter.  The  dread  of  inflamma- 
tion passes  off,  the  swelling  begins  to  diminish,  the  color  of  the 
skin  changes  from  black  and  purple  to  green  and  yellow,  the 
tender  points  can  be  touched  again,  and  a  certain  range  of 
movement  is  permitted  once  more,  though  in  a  tentative  and 
cautious  manner.  With  moderate  good  fortune  this  continues, 
until  at  the  end  of  two  or  three  weeks  the  injury  is  repaired, 
and  the  joint  as  sound  and  as  trustworthy  as  it  was  before. 
VerjT  often,  however,  it  happens,  as  time  goes  on,  that  the  im- 
provement becomes  more  and  more  slow,  until,  perhaps,  it 
comes  to  an  end  altogether,  and  the  joint  is  left  stiff,  painful, 
it  may  be,  and  almost  useless.  The  tissues  seem  to  have  been 
repaired,  but  freedom  of  movement  does  not  return. 

The  extent  to  which  this  suffers  differs  very  considerably. 
As  has  been  mentioned  already,  the  joint  may  be  merely  a 
little  weak  and  unsteady,  not  quite  to  be  relied  on,  perhaps, 
when  called  upon  for  any  special  effort ;  or  it  may  be  so  stiff 
and  rigid  as  to  give  rise  to  the  suspicion  that  the  bones  are 
grown  together,  and  the  cavity  completely  obliterated.  It 
may  be  perfectly  free  from  all  uneasiness  in  ordinary  circum- 
stances, or  it  may  be  the  seat  of  constant  aching,  with  frequent 
sharp  twinges  of  rheumatic  pain.  In  many  cases  it  may  be 
moved  without  inconvenience  up  to  a  certain  point,  but  the 


72  Sprains ;  their  Consequences  and  Treatment. 

least  attempt  to  carry  it  beyond  this  is  stopped  at  once  by 
pain,  and  a  sense  of  resistance.  Yet,  in  spite  of  this,  the  skin 
may  be  quite  cool,  and  the  tissues  of  the  joint,  to  all  appear- 
ance, perfectly  sound.  Sometimes,  in  cases  such  as  these,  it  is 
possible  to  find  a  definite  reason ;  a  tendon  may  be  displaced 
and  have  been  overlooked,  or  one  of  the  internal  portions 
thrown  out  of  gear;  secondary  changes,  such  as  wasting-  or 
spasmodic  rigidity,  may  have  made  their  appearance  in  the 
muscles;  or  the  capsule  may  be  so  relaxed  that  it  is  unable  to 
maintain  the  necessary  degree  of  pressure  on  its  contents;  but 
such  as  these,  for  this  reason,  must  be  dealt  with  by  them- 
selves. Those  to  which  I  wish  to  refer  at  present  are  alto- 
gether different ;  no  definite  lesion  is  to  be  found  in  them ;  they 
do  not  seem  to  have  been  severely  injured;  there  is  no  evidence 
that  the  amount  of  laceration  was  extensive ;  yet  they  remain 
so  stiff  and  painful  as  to  be  almost  useless,  without  any  ap- 
parent cause. 

The  severity  of  the  sprain  has  nothing  to  do  with  it.  It  is 
quite  as  common  after  slight  injuries  as  after  severe  ones. 
Indeed,  it  very  rarely  follows  complete  dislocations,  in  which 
the  laceration  is  most  extensive  of  all.  It  may  even  come  on 
without  injury  if  the  joint  has  been  inflamed;  no  matter  how 
slight  the  attack,  it  sometimes  leaves  behind  it  a  degree  of 
stiffness  that  lasts  for  years,  long  after  all  trace  of  the  excit- 
ing cause  has  passed,  and  without  there  being  any  gross 
change  to  explain  it. 

General  Appearance. — There  are  certain  features  about 
these  joints  by  which  they  may  usually  be  recognized.  If  it 
is  a  superficial  one,  like  the  knee,  the  skin  is  reddened,  but  not 
with  the  bright  flush  of  inflammation,  or  the  ruddy  glow  of 
use;  it  is  dusky  and  bluish,  and  if  the  finger  is  pressed  upon  it 
so  as  to  drive  the  color  out  it  is  very  slow  in  returning.  Often 
it  is  cold  to  the  touch ;  the  patient  may  declare  that  it  feels 
warmer  than  the  rest  of  the  limb,  and  even  complain  of  a  con- 
stant burning  pain,  but  as  tested  with  the  hand,  or,  better  still, 
with  a  surface  thermometer,  it  is  decidedly  cooler.  Sometimes 
the  skin  is  smooth  and  gloosy,  sometimes  wrinkled,  but  it  does 
not  fall  into  the  natural  folds  of  the  part,  or  glide  evenly  over 
the  bony  prominences  beneath.  It  seems  too  tight,  as  if  it 
were  shrunken,  and  it  cannot  be  pinched  up,  or  made  to  glide 
from  side  to  side  Frequently  one  or  two  spots  are  exquisitely 


Sprains ;  their  Consequences  and  Treatment.  73 

tender,  not  merely  when  firmly  pressed  upon,  but  even  if  a 
finger  touches  the 

The  tissues  round  are  wasted;  the  shape  of  the  bones  stands 
out  too  distinctly ;  the  hollows  are  not  filled  in  by  muscles  or 
by  fat  as  they  are  in  normal  health.  Even  in  joints  so  well 
covered  as  the  hip  and  shoulder  something-  of  this  can  gener- 
ally be  made  out  by  the  eye,  though  measurements  may  fail. 
Occasionally,  however,  this  is  concealed  by  the  swelling  of  the 
subcutaneous  tissue  round,  especially  in  the  case  of  the  ankle 
joint,  if  the  leg  has  been  allowed  to  hang  down  for  any  time 
before  it  is  examined. 

Impairment  of  Mobility. — The  most  prominent  feature, 
however,  in  connection  with  these  joints  is  the  interference 
with  their  movement.  The  limb  in  most  may  be  bent  more 
easily  than  it  can  be  straightened ;  but  it  is  seldom  that  it  can 
be  moved  to  its  full  extent  in  either  direction.  It  is  stopped 
abruptly  as  soon  as  a  particular  angle  is  reached ;  the  check 
is  so  sudden  and  so  firm  that  the  bones  seem  locked  together, 
and  any  attempt  to  force  it  further  only  causes  intense  pain 
shooting  through  the  joint,  often  most  severe  where  the  skin 
is  so  tender  to  the  touch.  Generally,  though  there  is  a  sense 
of  discomfort  and  apprehension  the  joint  can  be  moved  up  to 
this  point  without  much  distress,  but  occasionally  even  this  is 
not  possible.  The  pain  is  so  severe,  and  the  dread  so  great, 
that  before  the  part  is  touched  the  muscles  contract  and  hold 
it  rigid,  almost  in  spite  of  the  patients'  will.  It  is  literally  be- 
yond their  power  to  allow  the  movement  to  take  place;  the 
pain  is  to  them  so  intense  that  their  will  is  overcome  and  con- 
trol over  their  actions  lost 

Muscular  Eigidity. — In  these  cases  it  is  impossible  to  form 
an  opinion  without  anaesthetics.  When  the  muscles  are  re- 
laxed so  that  their  action  is  eliminated  from  the  question  alto- 
gether, and  there  is  no  longer  any  fear  of  causing  pain,  the 
part  may  be  examined  thoroughly,  and  it  is  easy  to  ascertain 
whether  the  check  is  entirely  the  result  of  muscular  rigidity 
or  whether  there  is  some  other  obstacle  in  addition.  Such 
cases  are  not  uncommon.  Brodhurst  mentions  one  in  which 
the  joint  was  so  stiff  and  motionless  as  to  give  rise  to  the  sus- 
picion that  the  bones  had  actually  grown  together;  when  the 
patient  was  under  an  anesthetic,  movement  was  almost  as 
free  as  it  is  naturally. 


74  Sprains ;  their  Consequences  and  Treatment. 

It  is  true  that  a  good  deal  of  information  may  be  gained, 
especially  in  children,  by  diverting  the  patient's  attention  from 
the  part,  and  carefully  manipulating  it  at  the  same  time. 
When  this  can  be  done,  it  is  often  discovered  that  the  actual 
range  of  movement  is  a  great  deal  wider  than  it  appeared  to 
be ;  but,  in  the  first  place,  this  is  not  always  possible ;  and  then, 
though  the  information  is  undoubtedly  of  very  great  service, 
it  is  never  quite  enough.  It  shows  beyond  question  that  the 
rigidity  is  due  in  some  degree  to  muscular  contraction ;  but  it 
entirely  fails  to  show  how  much.  It  is  only  possible  to  make 
certain  of  this  when  the  muscles  are  in  some  way  completely 
relaxed,  so  that  they  no  longer  enter  into  the  question. 

Creaking. — Creaking  or  grating,  as  the  surfaces  move  on 
each  other,  is  always  present  in  these  joints.  It  may  be  but 
the  faintest  sensation  of  friction,  only  to  be  perceived  by  press- 
ing the  hand  firmly  on  the  part,  as  if  two  smooth  silken  sur- 
faces were  being  rubbed  together;  or  the  noise  produced  as 
the  fluid  is  squeezed  from  one  side  of  the  joint  to  the  other  may 
be  distinctly  audible  to  those  around.  This,  of  course,  depends 
on  the  condition  of  the  lining  membrane  of  the  cavity,  whether 
it  has  merely  lost  the  polish  from  its  surface  or  is  covered  over 
with  folds  and  fringes,  which  project  from  all  round  the  margin 
into  the  interior. 

Bands  and  Adhesions. — It  is  a  matter  of  popular  belief 
that  there  is  in  these  joints  a  band  of  some  kind,  passing  across 
the  cavity  from  one  side  to  the  other,  independently  of  the 
lining  membrane.  When  at  rest  this  is  quite  loose;  as  the 
limb  moves  it  suddenly  becomes  tense,  and  stops  it  abruptly, 
causing  very  severe  pain  by  the  way  in  which  it  is  stretched. 
It  is  possible,  of  course,  that  a  structure  of  this  kind  is  devel- 
oped sometimes;  but  I  have  never  found  such  a  one  myself  in 
a  joint,  nor  am  I  aware  of  any  case  in  which  such  a  phenomenon 
has  been  recorded.  Its  presence  would  undoubtedly  furnish  a 
very  simple  explanation  of  symptoms  that  are  often  obscure ; 
but  it  possesses  the  objection  of  being  almost  too  simple.  It 
explains  all  the  facts  at  once,  in  such  a  plain  and  straightfor- 
ward manner,  that  in  the  absence  of  all  corroborative  proof, 
one  cannot  but  feel  a  certain  degree  of  scepticism  and  reluct- 
ance in  accepting  it. 

At  the  same  time  it  cannot  be  denied  that  the  evidence  on 
which  this  opinion  is  based  is  very  striking,  and  is  sadly  in 


Sprains ;  their  Consequences  and  Treatment.  75 

want  of  an  explanation.  A  joint  has  been  sprained  some  long- 
time  before,  and  for  years  has  remained  painful,  and,  compar- 
atively speaking-,  useless;  it  has  been  rested,  and  bandaged, 
and  blistered  over  and  over  again  without  the  least  benefit; 
any  attempt  to  move  it  is  slopped  at  once  by  the  pain;  every 
time  it  is  tried  it  becomes  swollen,  hot,  and  tender;  and  ap- 
parently drifts  down  into  a  worse  condition  than  it  was  before. 
All  of  a  sudden,  something  gives  way,  perhaps  with  an  audible 
snap ;  there  is  a  moment's  intense  pain ;  but  movement  is  re- 
gained, and  recovery  is  perfect  from  that  instant,  without  after 
trouble  or  ill  consquence  of  any  kind. 

A  good  many  cases  such  as  this  have  been  recorded  from 
time  to  time,  among  others  by  medical  men,  from  their  own 
personal  experience.  Sometimes  they  have  been  cured  by  a 
designed  plan  of  manipulation,  sometimes  by  an  accidental 
fall.  There  is,  however,  a  certain  amount  of  suspicion  that 
they  are  not  quite  so  cotamon  as  is  generally  believed,  for  it  is 
in  the  nature  of  people  to  spread  abroad  as  widely  as  they  can 
everything  that  savors  of  the  marvellous.  I  have  mj-self  met 
with  very  few  that  could  be  called  in  any  way  typical,  though, 
of  course,  instances  of  joint  disease,  in  which  great  improve- 
ment has  resulted  from  vigorous  passive  motion,  are  common 
enough.  One  instance  was  very  characteristic.  The  patient 
was  a  strong,  healthy  man  on  active  service,  who  had  been  in- 
valided home  owing  to  the  condition  of  his  knee.  (I  may  remark 
that  a  very  large  proportion  of  the  more  striking  cases  occur 
in  connection  with  this  joint.)  He  had  sprained  it  severely 
some  months  before  in  a  fall  from  his  horse,  and  as  it  was  con- 
siderable time  before  anything  could  be  done  for  him  the 
swelling  became  enormous.  Then  it  was  kept  absolutely  quiet 
in  a  straight  position  for  three  weeks.  Cold  was  applied,  but 
not  compression.  At  the  end  of  that  time  the  joint  was  ex- 
ceedingly stiff  and  painful,  but  still  he  managed  to  get  about 
upon  it,  and  it  improved  gradually,  up  to  a  certain  point.  It 
could  be  straightened  out  fairly  well,  but  could  only  be  bent 
through  about  twenty  degrees;  as  soon  as  this  angle  was 
reached  it  came  to  a  dead  stop,  and  any  attempt  to  carry  it 
further  only  caused  the  most  intense  pain  and  made  the  swell- 
ing worse.  At  the  time  that  I  saw  him  he  was  so  disabled 
that  he  was  only  able  to  go  upstairs  with  difficulty.  The  joint 
was  very  slightly  swollen;  so  far  as  could  be  detected  nothing 


76  Sprains ;   their  Consequences  and  Treatment 

was  out  of  place.  All  that  could  be  found  was  a  very  tender 
spot  on  the  inner  side  of  the  knee-cap,  where  the  pain  was 
always  most  intense.  Circumstances  at  the  time  rendered  it 
unadvisable  that  an  anaesthetic  should  be  administered,  and 
a  few  days  after  he  was  completely  cured  by  an  accident. 
Coming-  downstairs  he  tripped  suddenly,  throwing-  involuntarily 
the  whole  of  his  weight  on  the  affected  limb,  felt  something 
snap,  and  fainted  away  from  the  pain.  When  he  recovered 
the  joint  was  a  little  tender  over  the  old  spot,  but  it  could  be 
moved  as  freely  as  the  other.  There  was  no  increase  in  the 
amount  of  the  swelling,  and  the  pain  was  gone,  nor  did  it  re- 
turn. (Strange  cures  of  this  description  are  not  limited  to 
sprains,  as  the  following  extract  shows : — "  Persons  given  to 
meditation  must  often  have  found  ample  material  for  specula- 
tion in  endeavoring-  to  imagine  what  train  of  thought  could 
have  prompted  the  introduction  of  certain  surgical  procedures, 
or  led  to  the  first  trial  of  this  or  that  therapeutical  agent  in 
the  treatment  of  a  particular  disease.  What,  for  example, 
could  have  stimulated  the  first  idea  of  curing-  sciatica  by 
stretching-  the  sciatic  nerve;  certainly  the  task  of  finding-  a 
train  of  thought  which  should  conduct  to  that  conclusion  would 
be  a  severe  one.  Many  such  methods  have  doubtless  been  sug- 
g-ested  by  a  real  or  fancied  analogy  between  them  and  certain 
natural  accidental  occurrences,  and  in  this  sort  of  observation 
charlatans  in  all  ag-es  have  shown  themselves  singularly  apt. 
We  may  quote  a  couple  of  instances  of  recent  occurrence,  where 
the  cure  was  effected  under  circumstances  which  must  have 
sug-gested  to  bone-shakers  their  violent  and  unscientific,  but 
occasionally  successful  manipulations.  In  one  case  the  person 
had  been  almost  bedridden  for  many  weeks  from  sciatica;  still 
suffering-  acutely  from  the  attack,  but  a  trifle  less  in  pain,  he 
hobbled  forth  to  g-et  the  benefit  of  a  little  fresh  air ;  at  a  cross- 
ing he  was  roughly  pushed  by  a  passing-  vehicle,  and  after  a 
desperate  but  unavailing-  effort  to  preserve  his  equilibrium  he 
fell  on  the  road  in  the  midst  of  a  fairly  dense  traffic.  It  was 
only  when  he  had  regained  the  sidewalk  that  he  began  to  feel 
astonishment  at  the,  in  him,  remarkable  agility  shown  in 
jumping-  up  and  running  to  a  place  of  safety.  The  sciatica  had 
quite  disappeared,  and  had  not  returned  four  years  later.  In 
case  number  two  a  strain  had  been  followed  by  severe  pain  on 
movement  over  the  outer  condyle  of  the  right  elbow,  which 


Sprains ;  their  Consequences  and  Treatment.  jj 

lasted  for  several  months,  almost  incapacitating1  the  sufferer 
from  pursuing1  his  occupation  as  a  hairdresser.  There  was  no 
obvious  lesion,  but  no  treatment  was  attended  with  any  bene- 
fit. One  night,  on  leaving  work,  he  had  to  find  his  way  along- 
a  dark  passage,  in  which  the  cellar  door  had  inadvertently 
been  left  open.  Against  this  he  struck  himself  violently  on 
the  painful  spot,  giving  rise  to  such  pain  that  he  nearly  fainted. 
Within  a  day  or  two,  however,  as  the  effects  of  the  bruise  dis- 
appeared, the  other  pain  was  now  noticed  to  be  absent.  The 
facts  are  rather  curious,  although  it  must  be  confessed  it  is 
not  easy  to  see  how  to  formulate  any  practical  rules  of  treat- 
ment as  a  deduction  therefrom/') 

It  certainly  seems  possible  that  in  this  case  a  band  was  de- 
veloped in  connection  with  the  joint  during  the  long  period  of 
repose,  but  I  am  not  prepared  to  assert  that  it  was  in  the  in- 
terior of  the  sac.  The  tissues  were  very  much  swollen  for  a 
longtime  after  the  accident;  the  joint  was  never  moved;  a 
great  deal  of  effusion  was  thrown  out ;  the  soft  folds  that  exist 
round  the  knee-cap  were  immensely  thickened,  so  that  it  is 
possible  they  gradually  formed  a  connection  along  the  interior 
of  the  capsule  with  those  of  the  opposite  side ;  as  organization 
proceeded  the  union  gradually  increased  in  strength,  until  it 
was  firm  enough  to  check  the  movement  of  the  joint:  strain- 
ing on  it  caused  severe  pain  by  the  way  it  dragged  upon  the 
softer  tissues;  the  sudden  violent  jerk  tore  it  in  two,  and  re- 
stored free  movement.  But  it  must  be  admitted  that  this  does 
not  rest  on  any  direct  or  certain  evidence. 

Changes  in  the  Tissues. — Opportunities  for  examining  the 
interior  of  these  joints  must,  from  the  very  nature  of  things, 
be  quite  exceptional ;  and  the  difficulty  of  explaining  the  symp- 
toms is  not  diminished  by  the  fact  that  when  one  does  occur 
the  result  is  not  always  unequivocal.  In  a  large  proportion 
there  is  nothing  to  be  found  post-mortem ;  the  structures  ap- 
pear as  sound  and  as  healthy  as  could  be  wished ;  and  even 
where  there  is  something  definitely  wrong,  it  is  often  so  slight 
that  it  is  impossible  to  believe  symptoms  of  such  intensity  could 
be  due  to  it  alone.  Clearly,  the  conditions  upon  which  they 
depend  must,  in  the  majority  of  cases,  be  such  that  they  come 
to  an  end,  and  disappear  with  the  life  of  the  part.  Nor  is  it 
difficult  to  imagine  of  what  sort  and  kind  they  must  be. 
Changes  in  the  circulation  or  nutrition  of  the  tissues,  for  ex- 


78  Sprains ;   their  Consequences  and  Treatment. 

ample,  often  leave  no  trace  behind,  and  yet  may  cause  the 
most  serious  interference  with  the  way  in  which  the  work  is 
carried  out.  It  is  quite  enough  if  the  part  is  imperfectly  sup- 
plied with  blood  so  that  the  muscles  are  overloaded  with  waste 
products,  and  the  nerves  enfeebled  and  unable  to  play  their 
part  with  sufficient  energy.  There  need  be  no  actual  change 
apparent  to  our  present  methods  of  investigation ;  the  tissues 
may  be  merely  stiffened  from  disuse  and  badly  nourished,  un- 
able to  move  freely,  or  accommodate  themselves  to  each  other; 
there  is  no  need  of  more,  it  is  quite  sufficient,  without  having 
to  invoke  the  aid  of  conspicuous  alterations  in  structure. 

The  Interior  of  the  Joint. — Sometimes  there  is  an  excess 
of  fluid  in  the  interior;  more  often,  especialty  if  the  joint  has 
been  kept  at  rest  for  long,  the  quantity  is  diminished,  and  it  is 
nearly  always  thin  and  serous  in  character,  a  little  turbid,  and 
not  so  oily  as  it  should  be.  The  cartilages  are  never  much 
affected,  the  part  they  play  is  too  passive,  only  in  old  and  long- 
standing cases  they  lose  the  glistening  polish  from  their  sur- 
face, and  are  a  little  thinned.  The  capsule,  with  the  loose  tis 
sue  round,  as  a  rule,  shows  more;  instead  of  being  soft  and 
flexible,  so  that  it  falls  into  folds  as  the  joint  moves  in  one 
direction,  and  opens  out  again  as  it  moves  in  the  other,  it  is 
stiff  and  unyielding.  In  other  cases  it  is  irregularly  thickened, 
with  its  inner  surface  marked  by  folds  and  ridges,  in  which 
are  little  elevations  of 'the  lining  membrane;  or  at  the  point 
where  it  is  attached  to  the  bone,  and  the  fibres  diverge  some- 
what from  each  other,  there  is  an  accumulation  of  lymph  hold- 
ing them  together,  and  as  it  becomes  organized  making  one 
part  drag  unfairly  and  unevenly  on  the  rest ;  or,  again,  there 
is  an  old  extravasation  of  blood,  the  remains  of  some  larger 
quantity,  of  which  part  has  never  been  reabsorbed. 

Old  Extravasations  in  the  Wall. — In  one  case,  at  least, 
I  think  I  could  attribute  the  whole  of  the  symptoms  to  a  cause 
of  this  kind.  The  patient  was  a  man  of  more  than  middle  age, 
who  came  to  me  complaining  of  an  exceedingly  painful  and 
tender  spot  over  the  inner  side  of  the  knee  joint,  about  half  an 
inch  from  the  margin  of  the  knee-cap.  There  was  a  history 
of  his  having  struck  the  joint  against  a  sharp  piece  of  furni- 
ture on  this  particular  spot  some  weeks  before.  The  skin  itself 
was  freely  movable,  but  appeared  slightly  raised  and  puffy; 
there  was  no  dislocation  at  the  time  that  I  saw  him,  and  it 


Sprains ;  their  Consequences  and  Treatment.  79 

was  doubtful  if  there  had  been  any — at  least,  the  patient  had 
not  noticed  it.  The  pain  on  touching-  it  was  intense;  steady 
pressure  could  hardly  be  borne  at  first,  but  seemed  to  relieve 
it  afterward;  walking-,  particularly  going  upstairs,  and  set- 
ting the  extensor  muscle  of  the  leg  in  action,  were  both  very 
painful.  With  the  joint  itself  there  seemed  to  be  nothing 
wrong;  there  was  no  appreciable  excess  of  fluid,  and  the  ten- 
der spot  was  so  fixed,  that,  almost  certainly,  it  had  nothing 
to  do  with  the  formation  of  any  fringes  or  foreign  bodies  in 
the  interior.  The  suggestion  was  that  either  some  of  the 
fibres  of  the  muscle  inserted  into  the  capsule  had  given  way, 
or  that  there  had  been  a  small  haemorrhage  into  the  substance 
of  the  capsule  itself.  I  had  the  opportunity  of  examining  the 
joint  at  a  later  period,  and  was  able  to  verify  the  diagnosis; 
so  far  as  I  could  ascertain  the  muscular  fibres  were  intact ;  in 
the  substance  of  the  synovia!  membrane,  corresponding  to  the 
painful  spot,  there  was  a  small  hard  mass  projecting  further 
into  the  cavity  than  it  did  on  the  exterior,  probably  because 
there  was  least  resistance  in  this  direction.  It  seemed  to  be 
the  residue  of  an  old  extravasation ;  the  blood  had  been  effused 
between  the  fibres  of  the  capsule;  some  of  it  had  been  absorbed; 
the  rest,  owing-  to  the  protection  it  received  from  the  side  of 
the  knee-cap,  escaping  all  pressure,  had  become  organized  and 
formed  a  small  hard  nodule.  Probably  this  happens  in  many 
cases  without  material  consequence;  most  likely  in  this  par- 
ticular one  it  implicated  in  some  way  or  other  a  nerve  filament, 
and,  like  the  little  peculiar  tumors  known  as  painful  subcu- 
taneous tubercles,  when  it  was  touched  it  dragged  or  pressed 
on  the  nerve  and  gave  rise  to  stabs  of  acute  pain. 

Dry  Synovitis. — Barwell  has  described  under  the  name  of 
dry  synovitis,  another  condition  which  may  exist  in  some  of 
these  cases,  and  help,  in  a  measure,  to  account  for  the  symp- 
toms. There  is,  according  to  him,  a  deposit  of  fibrinous  mate- 
rial on  the  inner  surface  of  certain  parts  of  the  lining  mem- 
brane, probably  derived  from  the  fluid  which  collects  in  the 
joint  when  it  is  inflamed.  During  life  these  spots  are  so  painful 
that  the  patient  will  hardly  allow  them  to  be  touched,  and  can 
scarcely  be  persuaded  to  move  the  limb.  Sometimes  the  pain  is 
paroxysmal,  arid  often  periodic  in  character,  and  it  is  always 
severe  to  a  degree  which  bears  no  comparison  with  that  of 
ordinary  synovitis. 


8o  Sprains ;  their  Consequences  and  Treatment. 

Neuralgia. — Occasionally  the  pain  and  loss  of  power  are 
caused  by  a  kind  of  neuralgia,  which  attacks  joints  and  seri- 
ously interferes  with  their  freedom  of  action,  without  leaving 
behind  any  visible  evidence  of  its  existence.  These  may  be 
recognized  by  the  peculiar  periodic  character  of  the  pain,  and 
by  the  way  in  which  it  is  limited  to  certain  spots,  which  cor- 
respond fairly  well  to  the  places  where  the  nerves  penetrate 
the  fibrous  capsule.  The  skin  immediately  over  them  is  ex- 
quisitely tender  to  the  touch,  and  sometimes  puffy,  or  slightly 
swollen;  and  movement  is  limited,  because,  as  the  joint  bends, 
the  capsule  is  exposed  to  different  degrees  of  tension,  and  in 
certain  positions  the  affected  nerve  is  pressed  upon  or  stretched. 
The  check,  however,  in  these  is  rarely  so  abrupt  as  it  is  in  the 
others.  In  one  case  under  my  care  it  appeared  to  alternate 
with  supraorbital  neuralgia,  the  pain  sometimes  occurring  in 
one  locality,  sometimes  in  the  other,  but  scarcely  ever  being 
present  in  both  at  the  same  time.  The  patient,  who  was 
thoroughly  overworked,  was  readily  cured  by  rest  and  change 
of  scene. 

Tissue  Starvation. — In  a  large  number,  however,  this  ex- 
planation fails  as  well.  There  is  no  evidence  of  neuralgia ; 
there  is  no  gross  lesion  to  be  detected  anywhere;  no  increased 
effusion,  thickening,  or  adhesion;  the  tissues  simply  are 
wasted;  the  muscles  have  lost  their  power,  and  the  joint  is 
so  stiff  and  painful  that  it  is  almost  useless.  The  real  reason 
is  the  prolonged  want  of  use.  The  tissues  are  starved  and 
badly  nourished.  During  life  they  are  surrounded  and  bathed 
in  a  nutritive  fluid,  which  pours  out  through  the  walls  of  the 
vessels  and  permeates  them  in  all  directions.  It  spreads  every- 
where in  the  interstices,  giving  up  to  the  structures  with  which 
it  comes  in  contact  the  material  they  require  for  their  growth 
and  action,  and  taking  away  whatever  is  worn  out.  The  sur- 
plus is  drained  off  by  a  special  system  of  vessels,  the  absorb- 
ents, so  that  it  may  never  remain  stagnant.  The  rapidity  of 
its  flow  is  entirely  regulated  by  the  activity  of  the  tissues.  If 
they  are  in  constant  use,  a  larger  amount  of  blood  comes  to 
them;  more  of  this  plasma  passes  through  the  walls  of  the 
vessels  into  the  spaces  round ;  the  supply  of  nutritive  material 
is  greater,  and  the  waste  more  rapidly  carried  off.  If,  on  the 
other  hand,  the  part  is  kept  in  a  condition  of  absolute  repose, 
the  plasma  lies  stagnant  round  and  between  the  tissue  ele- 


Sprains;  their  Consequences  and  Treatment,  Si 

ments,  so  that  when  they  are  suddenly  called  upon  for  active 
work  they  are  unfitted  and  unable.  Until  the  free  current  of 
the  plasma  is  thoroughly  re-established  once  more,  recovery 
of  power  is  impossible.  When  this  is  effected  the  parts  regain 
their  strength  and  vigor  almost  of  themselves. 

Even  a  healthy  joint  that  is  kept  absolutely  at  rest  may  be 
so  badly  nourished  that  it  becomes  stiff  and  unfitted  for  work, 
especially  if  the  demand  is  urgent  or  severe.  If  it  has  been 
injured  or  inflamed,  so  that  there  is  a  larger  amount  of  waste 
and  greater  need  for  repair,  and  is  then  kept  motionless,  this 
result  is  almost  certain  to  occur. 

It  is  a  common  thing  to  call  such  joints  as  these  hysterical, 
merely  because  there  is  no  evidence  of  any  gross  or  conspicu- 
ous lesion ;  nothing,  for  example,  is  out  of  place,  and  no  band 
or  adhesion  can  be  detected.  But  it  is  more  than  doubtful 
how  far  this  is  correct.  "When  a  joint  becomes  stiff,  and  the 
muscles  wasted  because  they  have  been  disused  and  are  not 
properly  nourished,  it  ceases  to  be  purely  and  simply  hyster- 
ical. It  is  true  this  may  have  been  the  starting-point,  because 
of  this  the  joint  may  have  been  kept  at  rest  or  prevented  from 
enjoying  its  full  range  and  freedom  of  action;  but  when 
changes  of  this  description  have  once  made  their  appearance 
there  is  something  above  and  beyond  mere  hysteria.  There 
is  a  local  affection  which  can  only  be  cured  by  local  measures, 
and  which  must  be  cured  before  the  hysterical  condition  can 
disappear.  So  long  as  it  persists  the  patient  is  convinced,  and 
quite  rightly  convinced,  that  the  joint  cannot  be  used  freely  as 
it  ought  to  be.  It  is  quite  true  that  it  cannot,  and  until  it  has 
regained  its  freedom  of  action,  and  the  muscles  their  strength, 
it  is  hopeless  trying  to  convince  the  patient  that  it  can.  Hap- 
pily in  many  instances  the  changes  are  so  slight  that  the  joint 
recovers  if  it  is  only  used  in  a  moderate  degree ;  if,  for  example, 
under  the  influence  of  change  of  air,  or  change  of  interest,  the 
patient's  attention  can  be  diverted  from  it.  Often,  however, 
this  is  not  enough,  and  then  measures  must  be  taken,  first  to 
give  back  to  the  joint  its  complete  range  of  movement,  and 
then  to  restore  the  nutrition  of  its  tissues  so  that  they  may 
regain  their  power  and  activity. 


OHAPTEE  VII. 

TREATMENT.   COLD.   HEAT.    PRESSURE. 

IT  must  be  admitted  there  is  something-  very  unsatisfactory 
in  the  results  obtained  by  the  ordinary  methods  of  treatment. 
Even  when  the  greatest  care  is  taken,  when  every  precaution 
is  used,  tedious  convalescence  is  the  rule,  rapid  and  perfect  re- 
covery the  exception,  and  often,  owing'  to  carelessness  or  delay, 
the  joint  never  recovers  at  all.  It  is  left  weak  or  tender,  not 
so  trustworthy  as  it  was ;  prone  to  SAvelling-  with  the  least  ex- 
ertion, and  sensible  to  every  chang-e  of  weather,  so  that  there 
is  an  end  once  and  for  all  to  the  healthy  unconsciousness  that 
such  a  thing  as  a  joint  exists. 

The  reason  is  not  far  to  seek.  In  a  large  proportion  of 
cases  the  measures  adopted  are  altogether  insufficient;  in  some 
they  are  absolutely  wrong-,  when,  for  example,  a  joint  is  kept 
perfectly  quiet  until  it  becomes  hopelessly  stiff;  while  in  nearly 
all  the  time  that  is  of  the  greatest  value,  that  which  immedi- 
ately follows  the  accident,  is  allowed  to  pass  by  without  any- 
thing- being-  done,  and  completely  wasted. 

Whatever  plan  is  adopted  it  is  essential  to  beg-in  at  once. 
Every  moment  lost  makes  a  serious  difference.  The  injury 
is  not  confined  to  the  instant  of  the  accident.  The  blood  keeps 
pouring-  out  from  the  wounded  vessels  and  accumulates  in  the 
synovial  sac  and  the  interstices  of  the  tissues,  until  if  left  to 
itself  it  causes  such  an  amount  of  pain  and  tension  that  in- 
flammation is  bound  to  follow.  If  recovery  is  to  be  speedy  or 
sound  this  must  be  stopped  at  once,  or,  at  any  rate,  confined 
within  the  narrowest  limits.  When  once  it  has  left  the  ves- 
sels, and  become  extravasated,  it  serves  no  useful  purpose, 
whether  it  collects  in  the  cavity  of  a  joint  or  spreads  itself 
through  the  loose  tissues  of  the  limb.  It  separates  the  ends 
of  the  torn  lig-aments;  it  distends  the  synovial  sac  until  it  be- 
comes stretched  out  of  all  proportions,  and  when  it  is  absorbed 


Sprains ;   their  Consequences  and   Treatment.  83 

it  leaves  the  capsule  loose  and  flaccid,  so  that  the  joint  feels 
weak  and  powerless.  If  it  remains,  the  consequences  are  worse 
still ;  either  it  breaks  down  and  forms  an  abscess,  or;  as  already 
described,  becomes  organized  into  a  hard  unyielding1  mass, 
which  interferes  with  the  action  of  the  muscles  and  compresses 
the  nerves  so  that  free  use  of  the  limb  is  rendered  impossible. 

The  first  thing  to  be  done  then  is  to  check  the  bleeding 
into  the  tissues,  and  to  spread  out  over  as  large  an  area  as 
possible  the  fluid  that  has  escaped  already.  Then,  as  reaction 
sets  in,  as  the  part  becomes  warm  and  red,  and  as  the  quantity 
of  blood  circulating  through  the  uninjured  vessels  begins  to 
increase,  steps  must  be  taken  to  keep  this  well  within  bounds. 
There  must  be  a  certain  increase;  it  is  essential  for  repair; 
the  injury  entails  more  work;  there  is  a  larger  quantity  of 
worn-out  material  to  be  removed  and  replaced,  and  more  blood 
is  required  for  it.  Only  it  must  be  kept  strictly  within  limits, 
and  not  allowed  to  run  on  until  the  synovial  sac  and  tendon 
sheaths  become  distended  or  inflammation  itself  sets  in. 

If  this  can  be  done  little  further  is  required.  All  that  re- 
mains is  to  assist  the  circulation  through  the  tissues  in  every 
way,  to  maintain  the  nutrition  at  its  highest  level,  and  by 
gentle  passive  motion  prevent  the  limb  becoming  stiff.  Repair 
takes  place  with  very  different  rapidity  in  different  people  and 
in  different  ages,  but  ligaments  that  have  given  way,  or  that 
have  sustained  many  small  injuries  in  their  substance,  natu- 
rally cannot  in  any  circumstances  be  repaired  at  once. 

Cold. — When  the  matter  is  thought  out  there  is  something 
almost  ludicrous,  if  such  serious  consequences  did  not  follow, 
in  the  general  way  in  which,  as  a  matter  of  routine,  a  wet 
bandage  is  applied  to  a  sprained  ankle.  For  the  moment  it  is 
cool  and  pleasant,  and  with  the  folds  and  turns  lying  evenly 
and  smoothly  on  each  other,  looks  exceedingly  neat.  The 
uniform  pressure  does  give  relief  at  first,  but  in  a  very  few 
minutes  the  coolness  disappears  and  the  temperature  is  as 
high  as  that  of  the  joint  beneath.  In  a  few  more  it  begins  to 
dry,  and  as  it  dries  it  becomes  loose,  so  that  the  pressure 
(which  never  at  any  time  falls  quite  in  the  right  part)  disap- 
pears altogether.  If  the  bandage  is  removed  and  the  limb  ex- 
amined it  is  smooth  and  round,  with  the  hollows  quite  filled 
up.  The  bandage,  of  course,  passes  over  them  without  press- 
ing upon  them,  reserving  this  for  the  bony  prominences  which 


84  Sprains ;  their  Consequences  and  Treatment. 

do  not  require  it.  The  soft  tissues  are  swollen  and  cedema- 
tous,  and  the  sy  no  vial  sac  and  the  tendon  sheaths  distended 
with  fluid. '  Applying  it  again  in  the  same  fashion  does  no 
good,  nor  is  it  of  any  use  keeping  the  bandage  wet.  The  prin- 
ciple is  correct,  but  the  method  of  application  altogether  a  fail- 
ure. Neither  the  cold  nor  the  pressure  is  applied  effectually, 
and  the  result  of  this  method  of  treatment  may  be  seen  in  the 
fullness  and  swelling  that  persist  round  ankles  for  years  after 
they  have  been  sprained. 

The  fault  is  not  that  of  the  cold.  This  is  one  of  the  most 
useful  and  satisfactory  applications  known.  It  may  be  dry  or 
moist;  it  does  not  matter  how  it  is  obtained.  The  limb  may 
be  surrounded  with  ice  or  cold  spring  water  poured  over  it,  or 
it  may  be  immersed  in  the  water,  or  any  other  method  adopted 
that  suggests  itself  at  the  moment.  The  important  point  is 
that  it  should  be  applied  at  once,  and  that  the  limb  should  not 
be  allowed  to  recover  its  temperature  until  a  more  permanent 
application  is  ready.  Used  in  this  way,  as  a  first  agent,  cold 
is  simply  invaluable.  It  is  always  at  hand,  any  one  can  apply 
it,  and  it  fulfills  every  indication.  The  blood-vessels  contract 
at  once,  the  skin  becomes  white,  the  bleeding  is  checked,  the 
sensitiveness  to  pain  is  diminished,  and  the  tendency  to  swell- 
ing very  much  lessened. 

If,  however,  it  is  used  in  a  hap-hazard  sort  of  way,  as  it  is 
under  a  wet  bandage,  if  the  limb  is  allowed  to  grow  warm  from 
time  to  time,  the  whole  of  the  benefit  is  lost.  Reaction  follows 
as  the  effect  passes  off;  the  blood-vessels  dilate  again  until  their 
diameter  is  much  larger  than  it  was  before.  More  blood  flows 
through  the  skin  and  the  adjacent  parts;  a  larger  quantity 
pours  out  where  the  vessels  are  torn;  the  temperature  rises; 
the  sensitiveness  of  the  skin  is  increased;  it  begins  to  glow, 
and  the  patient  becomes  conscious  that  the  joint  is  increasing 
in  size.  In  reality  more  harm  is  done  in  this  way  than  if  the 
the  part  is  left  entirely  to  itself.  In  some  people  who  are  more 
than  usually  susceptible,  it  is  enough  to  produce  results  of 
exactly  the  opposite  character  to  those  intended,  and  in  the 
later  stages  of  sprains,  when  the  joint  is  cold  and  powerless, 
it  is  used  in  this  way  for  this  very  purpose.  The  alternate 
action  of  cold  and  w^armth  is  one  of  the  most  effectual  meas- 
ures known  for  stimulating  the  circulation  through  a  part, 
and  if  employed  soon  after  the  infliction  of  such  an  injury  as 


Sprains ;   their  Consequences  and  Treatment.  85 

a  sprain,  before  the  ends  of  the  vessels  have  had  time  to  close, 
certainly  does  more  harm  than  good. 

As  a  Temporary  Application. — It  is  equally  important 
that  the  application  should  not  be  continued  too  long1.  As  an 
immediate  and  temporary  expedient  cold  can  scarcety  be  sur- 
passed, but  after  a  time  a  condition  of  passive  congestion  sets 
in.  The  nerves  and  the  delicate  muscular  fibres  on  which  the 
contraction  of  the  vessels  depends  become  paralyzed;  the  part 
becomes  red  and  swollen,  in  great  measure  from  the  blood  that 
lies  stagnant  in  it ;  the  skin  is  anaemic,  shrunken,  and  rough 
from  the  upstanding  papilla?;  the  amount  of  blood  and  lymph 
in  the  tissues  is  sufficient,  but  it  is  never  changed ;  the  vitality 
of  the  part  is  lowered;  the  nutritive  changes  on  which  repair 
depends  are  carried  on  more  feebly,  and  if  the  process  is  con- 
tinued may  stop  altogether,  so  that  the  part  either  actually 
perishes  or  is  attacked  by  a  IOAV  form  of  inflammation.  Even 
when  the  effect  falls  far  short  of  this,  long-continued  cold 
brings  about  a  state  of  things  in  the  tissues  that  is  by  no 
means  favorable  to  the  repair  of  injury. 

Method  of  Application. — Cold  may  be  applied  hi  a  multi- 
tude of  ways,  but  as  a  rule  the  simpler  the  method  the  better. 
It  may  be  dry  or  moist.  In  the  former  case  it  acts  by  con- 
duction only;  in  the  latter  by  evaporation  as  well,  but  it  is 
possible  this  advantage  is  more  apparent  than  real.  It  is 
much  more  important  that  time  should  not  be  lost,  and  that 
the  injured  limb,  especially  if  it  is  the  ankle,  should  not  be 
allowed  to  hang  down,  as  it  nearly  always  is.  In  some  parts 
of  the  body,  such  as  the  hip,  there  is  no  doubt  of  the  superior 
comfort  of  the  dry  method ;  in  others  the  position  in  which  the 
limb  must  be  placed,  and  the  facility  with  which  the  cold  can 
be  applied,  form  the  best  guide. 

Cold  spring  water  is  nearly  always  at  hand.  It  may  be 
either  poured  freely  over  the  injured  part,  or  this  may  be  im- 
mersed in  it.  The  former  plan  is  the  more  efficacious;  inde- 
pendently of  the  fact  that  fresh  quantities  of  water  are  contin- 
ually being  brought  into  contact  with  the  skin  and  abstracting 
heat  from  it,  and  that  a  certain  amount  of  evaporation  can 
take  place  as  well,  it  is  probable  that  the  actual  impact  of  the 
calling  water,  perhaps  by  the  shock  and  the  influence  it  has 
on  the  nerves  in  making  the  vessels  contract,  perhaps  by  the 
force  of  its  fall,  is  of  great  assistance.  As  soon  as  the  joint 


86  Sprains ;   their  Consequences  and  Treatment. 

ceases  to  swell  and  the  skin  is  beginning-  to  look  dull  and  livid, 
the  maximum  amount  of  benefit  has  been  produced.  It  is 
rarely  advisable  (at  any  rate,  if  pressure  can  be  applied)  to 
carry  it  any  further. 

The  same  effect  may  be  produced  by  immersion,  but  unless 
the  water  is  very  cold  it  is  much  more  slow,  probably  because 
the  layer  next  to  the  skin  is  soon  warmed  to  the  temperature 
of  the  body.  If  ice  can  be  obtained  at  once  in  sufficient 
quantity,  the  result  is  as  rapid,  but  there  is  the  disadvantage 
that  it  is  nearly  always  necessary  to  allow  the  limb  to  hang 
down,  a  position  which  should  always  be  avoided,  as  it  tends  to 
increase  the  amount  of  blood  in  the  part,  and  sometimes  makes 
it  much  more  painful. 

Continuous  Application. — A  few  days  after  the  accident, 
if  by  any  mischance  inflammation  does  set  in,  cold  may  be 
applied  continuously,  but  then  the  reason  is  not  the  same.  In 
these  circumstances  it  may  be  kept  up  for  an  indefinite  length 
of  time.  The  object  is  to  diminish  the  amount  of  blood  circu- 
lating through  the  part,  and  so  to  lower  the  temperature  and 
reduce  the  inflammation.  But  in  sprains,  ordinarily  speaking, 
there  is  not  any  inflammation  to  reduce.  As  Hood  and  many 
others  have  pointed  out,  .there  is  absolutely  no  reason  why, 
when  a  sprain  occurs  in  a  healthy  person,  and  is  treated  with 
a  reasonable  amount  of  care,  this  complication  should  set  in 
more  often  than  it  does  in  the  case  of  simple  fracture. 

The  most  convenient  fashion  for  its  continuous  application 
is  by  a  set  of  Leiter's  coils.  They  may  readily  be  improvised  out 
of  India-rubber  tubing  (the  best  is  that  which  has  an  internal 
diameter  of  about  one-third  of  an  inch  and  moderately  thin 
walls),  or  better  still  from  composition  gas-piping,  which  has 
the  advantage  of  retaining  the  shape  to  which  it  is  bent.  They 
may  be  applied  to  any  part  of  the  body,  coiled  round  a  limb, 
for  example,  without  the  circles  being  in  any  way  fastened  to- 
gether, or  wound  in  a  flat  spiral  and  rested  on  the  part,  as  in 
the  groin,  or  pressed  into  the  shape  of  a  low  cone  and  arranged 
to  fit  the  shoulder.  All  that  is  necessary  is  that  there  should 
be  two  buckets,  one  containing  water  of  the  desired  tempera- 
ture placed  on  a  stool  a  little  higher  than  the  limb,  and  con- 
nected with  one  end  of  the  coil  by  means  of  a  piece  of  tubing ; 
the  other,  on  a  lower  level,  empty,  and  connected  with  the 
other  end.  As  soon  as  the  current  is  started  from  one  to  the 


Sprains ;  their  Consequences  and  Treatment.  87 

other  the  flow  is  continuous,  and  may  be  regulated  with  the 
greatest  accuracy.  It  is  not  essential  that  the  cold  should  be 
confined  strictly  to  the  part  actually  inflamed.  If  an  ice-bag- 
is  laid  on  a  limb  over  the  course  of  one  of  the  main  arteries 
it  causes  a  very  sensible  diminution  in  the  temperature  of  the 
part  below  by  the  constriction  it  induces,  and  by  the  propor- 
tionate diminution  in  the  amount  of  blood. 

There  are  other  methods  as  efficacious,  but  less  convenient. 
One  depends  on  the  well-known  fact  that  if  a  skein  of  wool  is 
allowed  to  hang  over  the  edge  of  a  vessel,  so  that  one  end  dips 
in  the  fluid  inside  and  the  other  hangs  over  the  edge,  a  continu- 
ous stream  of  drops  will  come  from  the  dependent  half  until 
all  the  fluid  is  gone.  A  drip  pot  of  this  kind,  or  more  than 
one,  suspended  over  a  limb  and  filled  with  evaporating  lotion 
reduces  the  temperature  quite  far  enough.  Iced  water,  or  a 
lotion  containing  chloride  of  ammonium  in  solution,  answers 
very  well,  but  if  the  full  effect  is  desired  there  is  nothing  to 
equal  lead  lotion  mixed  with  spirit,  and  containing  a  few  frag- 
ments of  ice.  The  effect  is  greater  in  proportion  to  the  amount 
and  strength  of  the  spirit.  It  may  be  allowed  to  drip  on  to 
the  skin  directly,  or  this  may  be  covered  with  a  single  thick- 
ness of  lint,  so  as  to  avoid  splashing,  and  to  carry  off  the 
surplus  fluid.  If  the  lint  is  folded  even  once,  so  that  there  are 
two  layers,  evaporation  is  checked  to  a  considerable  extent, 
and  a  great  deal  of  the  effect  lost. 

Arnica,  which  is  frequently  recommended  in  the  early  stages 
of  sprains,  is  worse  than  useless.  The  sole  merit  that  it  pos- 
sesses is  due  to  the  spirit  that  is  mixed  with  it,  and  it  has 
the  very  serious  defect  of  exciting  in  many  people  (especially 
when  it  is  not  very  much  diluted)  a  peculiar  form  of  inflam- 
mation of  the  skin,  which  is  not  only  very  difficult  to  distin- 
guish from  erysipelas,  but  which  is  very  likely  to  run  on  into 
it.  Aconite,  too,  may  be  mentioned  here  as  occasionally  of 
service  when  one  or  two  small  spots  are  exceedingly  tender, 
but  care  must  be  taken,  especially  when  it  is  mixed  with 
chloroform,  that  it  is  not  applied  over  too  large  a  surface. 

A  still  more  simple  wa.y  of  applying  cold  is  to  fill  an  India- 
rubber  bag  (or  where  this  is  not  handy  an  ordinary  bladder 
answers  all  the  purpose)  with  small  fragments  of  ice,  or  with 
ice  and  salt,  and  to  allow  it  to  hang  over  the  joint  so  as  just 
to  be  in  contact  with  it.  A  double  fold  of  lint,  or  a  thin 


88  Sprains ;  their  Consequences  and  Treatment. 

pocket-handkerchief,  must  be  placed  underneath,  lying-  on  the 
skin  and  changed  occasionally,  as  it  soon  becomes  wet  from 
the  condensation  of  moist  air  on  the  outside  of  the  bag-.  This 
plan  is  particularly  useful  when  it  is  desirable  to  produce  an 
effect  on  deep-lying-  structures,  or  to  keep  the  cold  up  for  a 
considerable  leng-th  of  time,  as  it  is  very  effectual,  may  be 
graduated  exactly,  does  not  want  watching,  and  makes  no 
mess. 

Cold  is  most  successful  in  sprains  of  large  joints  when  the 
swelling  comes  on  rapidly.  If  twelve  or  more  hours  pass  by 
before  this  makes  its  appearance,  pressure  applied  early  an- 
swers a  great  deal  better,  though  even  then,  if  a  joint  such  as 
the  knee  or  ankle  has  been  bandaged  carefully,  an  ice-bag  laid 
on  it  makes  its  influence  felt,  and  helps  to  relieve  the  feeling 
of  tension  and  throbbing.  When  the  brunt  of  the  injury  is 
borne  by  the  muscles  it  is  not  nearly  so  serviceable.  In  the 
aged,  in  the  very  young,  in  those  subject  to  local  congestions 
such  as  chilblains,  and  in  the  rheumatic,  it  must  be  used  with 
great  caution,  and  the  skin,  if  it  is  moistened,  must  be  dried 
with  the  greatest  care;  otherwise  it  may  happen  that  the  de- 
pression due  to  the  cold  insensibly  shades  off  into  an  attack  of 
inflammation,  the  very  thing  it  is  intended  to  prevent. 

Heat. — Heat  may  be  employed  in  many  cases  in  which  the 
use  of  cold  does  not  seem  advisable.  Its  value  as  an  immediate 
application  depends  on  the  fact,  which  is  not  so  widely  known 
as  it  might  be,  that  hot  water,  if  the  temperature  is  suffi- 
ciently high,  is  as  effectual  in  stopping  bleeding  as  ice.  The 
skin  becomes  cold,  the  vessels  in  it  and  in  the  layer  immedi- 
ately beneath  contract,  and  the  circulation  in  many  instances 
almost  stops.  In  the  case  of  the  fingers,  where  in  proportion 
to  their  thickness  the  extent  of  surface  is  very  great,  I  have 
seen  complete  blanching  and  numbness  produced  by  dipping 
the  hand  into  very  hot  water,  and  have  known  it  last  even  in 
the  hot  days  of  summer  for  many  hours,  longer  than  if  it  had 
been  due  to  the  application  of  ice. 

To  produce  such  an  effect  as  this  the  temperature  of  the 
water  must  be  as  hot  as  can  be  borne.  It  cannot,  therefore, 
be  kept  up  for  more  than  a  few  moments,  for  fear  the  skin 
may  be  injured ;  and  for  the  same  reason  it  cannot  be  em- 
ployed, as  cold  is,  to  diminish  the  calibre  of  the  vessels  in  the 
deeper -lying  structures.  Its  value  is  greatest  when  the  in- 


Sprains ;   their  Consequences  and  Treatment.  80 

» 

jured  part  lies  near  the  surface,  particularly  in  the  case  of 
tendons,  which,  like  those  on  the  back  of  the  hand,  run  a  long- 
distance down  into  the  fingers,  tying-  immediately  under  the 
skin  the  whole  way.  In  the  ankle  and  elbow,  also,  it  succeeds 
fairly  well,  but  the  difficulty  of  application  in  the  case  of  other 
joints  is  so  great  that  it  is  generally  better  to  rely  on  cold. 

The  temperature  of  the  water  requires  a  good  deal  of  judg- 
ment, especially  as  different  people,  even  different  parts  of  the 
body,  vary  very  much  in  their  degree  of  tolerance.  With 
children,  it  is  particularly  necessary  to  be  careful,  as  their 
skin  is  so  delicate.  Happily  in  them  joint  sprains  are  not  so 
common  as  they  are  in  adults.  The  fingers  can  stand  a  higher 
temperature  than  the  hand,  and  this,  again,  a  much  higher 
one  than  the  elbow;  indeed,  the  point  of  the  elbow  is,  so  far 
as  heat  is  concerned,  one  of  the  most  sensitive  parts  of  the 
body.  The  extent  of  surface  immersed  has  to  be  considered, 
too.  It  must  not  be  forgotten  that  the  sensitiveness  to  heat 
increases  with  the  area  exposed.  It  is  not  a  bad  plan  to 
place  the  limb  in  hot  water,  and  then  raise  the  temperature 
rapidly  by  adding  more,  until  it  is  as  high  as  the  patient  can 
stand,  taking  care  to  stir  it  round  all  the  while,  so  as  to  dis- 
tribute the  heat  evenly  through  the  whole.  Two  or  three 
minutes  ought  to  be  sufficient ;  often  the  full  effect  is  gained  at 
the  end  of  the  first. 

Heat  used  in  this  way  has  a  wonderful  power  of  relieving 
pain.  The  skin  may  not  be  blanched,  but  its  sensitiveness  is 
lowered ;  manipulation  is  more  easy,  and  displaced  tendons  or 
other  structures  can  be  restored  to  their  position  without  the 
sickening  sense  of  over-stretched  fibrous  tissue.  It  is  worth 
noting,  moreover,  as  another  point  in  its  favor,  that  the 
effects  are  more  lasting  than  those  of  cold,  and  consequently 
time  is  gained  for  the  application  of  other  and  more  perma- 
nent measures,  such  as  massage  and  bandaging. 

Sometimes,  after  prolonged  overwork  or  severe  strains,  the 
bony  prominences  to  wThich  the  muscles  are  attached  become 
sore  and  tender,  or  the  tendon  sheaths  seem  to  be  roughened 
and  uneven,  so  that  perfect  smoothness  of  motion  is  lost;  or 
in  certain  classes  of  work,  where  without  the  actual  exertion 
being  great,  rapidity  and  delicacy  of  movement  are  carried  to 
a  very  high  pitch,  the  nerves  become  painful,  and  the  muscles 
liable  to  sudden  and  spasmodic  contractions.  When  this  oc- 


9°  Sprains ;   their  Consequences  and  Treatment, 

curs  the  prolonged  application  of  warmth  may  generally  be 
relied  upon  to  give  relief,  at  any  rate  for  a  time.  A  moderate 
temperature  usually  suffices.  The  object  is  not  to  numb  the 
sensibility  of  the  part,  but  rather  to  relax  the  walls  of  the 
vessels  and  relieve  the  tension,  so  that  blood  may  circulate  more 
freely  through  the  tissues,  and  the  delicate  fibres,  in  which  the 
nerves  end,  may  no  longer  be  kept  upon  the  stretch.  This 
holds  good  even  when  some  of  the  muscular  fibres  have  been 
torn  across  or  rent  from  their  attachments. 

Later,  when  the  joint  is  beginning  to  recover  and  movement 
is  returning,  heat  is  of  value  both  for  its  own  merits  and  as  a 
preliminary  to  massage.  There  is  then  no  limit  to  the  length 
of  time  it  may  be  applied.  The  hand,  for  example,  if  it  is  stiff 
from  the  effects  of  some  old  sprain,  may  be  kept  soaking 
for  hours  in  water  as  hot  as  can  be  borne  with  the  greatest 
benefit.  The  tissues  become  soft,  everything  is  supple  and 
flexible,  the  constant  aching  disappears,  and  movements  which 
before  were  out  of  the  question  are  executed  with  ease  and 
freedom ;  only,  unfortunately,  it  rarely  happens  that  the  whole 
of  the  improvement  is  retained.  So  far  as  stiffened  joints,  at 
least,  are  concerned,  it  does  not  seem'  improbable  that  the 
reputation  enjoyed  by  many  of  the  foreign  baths  is  due  more 
to  the  temperature  of  the  water  and  the  length  of  time  the 
limbs  are  allowed  to  steep  in  it  than  to  anything  else,  though 
it  is  not  denied  that  in  other  respects  they  may  be  of  consid- 
erable service. 

Besides  these  there  are  other  methods,  less  general  in  their 
application,  which  are  better  described  in  the  treatment  of 
special  sprains.  Ironing,  for  example,  is  often  of  great  use 
where  large  masses  of  muscle  in  the  loins  are  stiff  and  painful 
from  overwork  or  cold,  so  that  the  patient  cannot  move  with 
freedom  or  even  hold  himself  erect;  and  hot  vapor  or  mud 
baths,  where  the  limbs  are  stiff  and  crippled  from  old  attacks 
of  inflammation,  frequently  procure  great  relief  from  pain; 
but  remedies  of  this  description  must  be  dealt  with  by  them- 
selves. As  a  rule,  they  are  used  in  conjunction  with  others, 
and  do  not  depend  for  their  merit  on  heat  alone. 

Heat  and  Cold  Alternately. — Later  still,  when  the  repair 
of  the  tissues  is  perfect,  but  full  use  is  not  restored,  nothing 
can  be  more  successful  than  the  alternate  action  of  heat  and 
cold.  Some  weeks,  perhaps,  have  passed  since  the  joint  was 


Sprains ;  their  Consequences  and  Treatment.  91 

hurt;  all  fear  of  inflammation  has  been  dispelled;  there  is 
nothing1  out  of  place;  no  bands  or  adhesions  to  hurt  the  move- 
ment; no  very  tender  spot,  though  the  whole  may  ache,  es- 
pecially after  it  has  been  used;  but  there  is  no  power  in  it. 
The  joint  is  colder  than  its  fellow ;  the  skin  is  livid  and  wrinkled, 
fitting-  closely  on  to  the  bones,  and  often  sligiitly  swollen 
where  it  stretches  over  the  hollows  between  them ;  the  position 
of  the  parts  is  natural  and  good;  one  bone  can  be  moved  upon 
the  other,  though,  perhaps,  not  quite  to  its  full  extent ;  but  the 
part  looks  and  feels  as  if  it  were  only  half  alive,  able  to  put  out 
half  the  energy  it  should.  Sometimes,  it  is  true,  this  is  the 
result  of  defective  energy  and  will  in  the  great  nerve  centres, 
but  often  the  fault  lies  in  the  part  itself.  The  tissues  round 
the  joint  have  been  at  rest  so  long,  have  been  so  long  without 
doing  anything  for  themselves,  that  they  have  almost  lost  the 
power.  The  circulation  through  them  has  been  at  its  lowest 
ebb  for  such  a  length  of  time,  that  when  a  sudden  demand  is 
made  upon  it  it  is  unable  to  respond.  In  these  circumstances 
the  shock  of  alternate  heat  and  cold  acts  as  a  most  powerful 
stimulus,  especially  when  used  in  the  form  of  a  douche,  pro- 
jected with  some  force  and  suddenness  against  a  part  which 
has  been  allowed  to  soak  in  hot  water.  The  skin,  of  course, 
receives  the  greatest  amount  of  effect,  and  sometimes,  espe- 
cially with  the  needle  douche,  a  great  deal  more  has  been  done 
than  was  desirable ;  but  the  whole  circulation  through  the  part 
is  quickened;  the  volume  of  blood  increases;  the  nutrition  of 
the  tissues  is  carried  on  more  as  it  is  in  normal  health,  and 
the  muscles  and  nerves  begin  at  once  to  regain  their  power. 
Aided  by  galvanism  and  other  measures,  it  is  surprising  how 
this  method  of  treatment  restores  tone  to  the  muscles,  and 
causes  the  absorption  of  chronic  exudations  that  perhaps  have 
remained  passive  and  unaltered  for  years;  only,  partly  from 
the  very  ease  with  which  it  may  be  applied,  it  is  not  advisa- 
ble that  this  line  of  treatment  should  be  carried  out  without 
suitable  supervision ;  or  more  harm  than  good  may  easily  be 
done. 

Pressure. — This  is  not  the  only  plan  which  illustrates  the 
value  of  a  time-honored  practice,  when  carried  out  thoroughly, 
and  its  worthlessness  as  usually  employed.  Bandaging  for 
sprains  is  almost  universal,  and  well  deserves  its  reputation ; 
it  must  be  carried  out  systematically  and  rationally,  with 


92  Sprains;   their  Consequences  and  Treatment. 

a  proper  regard  to  the  structure  of  the  joint,  the  arrangement 
of  the  parts  round  it,  and  the  movements  it  ought  to  perform ; 
and  this  implies  anatomical  and  surgical  knowledge  of  no  mean 
order. 

Heat  and  cold  are  only  of  temporary  use;  their  influence 
on  the  vessels  is  exerted  through  the  nerves  and  muscles,  and 
after  a  time  these,  like  other  vital  structures,  become  tired  out, 
relax,  and  give  way.  Both  of  them  when  continued  too  long 
help  to  produce  the  very  effect  they  are  intended  to  prevent. 
The  tissues  become  congested;  the  circulation  is  checked, 
though  the  actual  amount  of  blood  in  the  part  may  even  be 
greater  than  normal;  the  cavity  of  the  joint  is  distended;  and 
the  soft  tissues  round  and  between  the  bony  prominences  are 
filled  with  exudation,  which  becomes  organized,  develops  into 
tough  and  unyielding  fibrous  bands,  and  cripples  the  move- 
ment of  the  joint  in  all  directions. 

As  compared  with  these  the  action  of  pressure  is  entirely 
mechanical;  the  measure  may  be  graduated  according  to  the 
needs  of  each  case,  and  it  may  be  kept  up  at  any  required  de- 
gree for  an  indefinite  period  of  time.  When  carefully  and 
methodically  applied,  nothing  can  be  more  efficient  for  stopping 
bleeding,  or  for  insuring  the  absorption  and  dispersal  of  blood 
that  has  escaped  already.  It  controls  the  hypersemia  and 
checks  the  dilatation  of  the  vessels,  so  that  the  outpouring 
of  the  plasma  into  the  tissues  is  restrained  within  proper  limits. 
It  prevents  the  accumulation  of  fluid  in  the  synovial  cavities; 
assists  the  absorption  of  plasma  from  protected  spots,  so  that 
it  neither  runs  on  to  inflammatory  exudation  on  the  one  hand, 
nor  becomes  organized  and  leads  to  stiffening  of  the  joint  on 
the  other;  and  above  all  it  relieves  pain  in  the  most  wonderful 
way,  whether  it  is  the  sharp  and  acute  kind  that  comes  on 
immediately  after  an  accident,  due  to  the  stretching  and  tear- 
ing of  the  nerves  in  the  ligaments  and  fibrous  structures,  or 
the  dull  aching  afterward  caused  by  the  continued  tension  on 
the  capsule.  In  the  majority  of  instances,  if  compression  is 
properly  applied,  the  swelling  disappears  by  the  next  day,  and 
the  joint  may  be  moved  through  nearly  its  whole  range  with- 
out more  than  a  sense  of  discomfort. 

Method. — To  bring  about  this  result,  however,  the  com- 
pression must  be  applied  with  a  definite  knowledge  of  what  is 
desired,  and  how  it  is  to  be  obtained.  Merely  putting  a  band- 


Sprains ;  their  Consequences  and  Treatment.  93 

age  on  a  limb  that  has  been  sprained  is  only  liable  to  perpet- 
uate the  very  evil  it  is  intended  to  prevent. 

It  may  be  commenced  at  once,  as  soon  after  the  accident 
as  practicable,  or  heat  or  cold,  as  the  case  may  indicate,  may 
be  applied  for  a  short  time  first.  Probably  in  most  cases 
the  latter  plan  is  the  better;  heat  or  cold  requires  less  skill, 
and  relief  from  pain  is  attained  more  immediately,  while,  if 
carried  out  effectually,  time  is  not  really  lost.  Besides,  before 
a  bandage  can  be  applied,  it  is  necessary  to  make  perfectly 
certain  that  there  is  no  displacement  of  any  kind.  If  there  is 
anything-  of  the  sort  it  must  be  made  out  and  rectified  before 
further  steps  are  taken ;  it  is  hopeless  trying  to  cure  a  sprained 
joint  if  any  of  the  structures  belonging-  to  it  are  out  of  their 
natural  position.  How  far  it  may  be  advisable  in  these  cir- 
cumstances to  make  use  of  massage  as  a  preliminary,  is  a 
question  that  is  best  dealt  with  by  itself. 

The  method  of  application  is  all  important,  though  the 
rules  that  guide  it  are  sufficiently  simple.  The  joint  must  be 
fixed  in  the  most  suitable  position,  not  necessarily  the  one  se- 
lected by  the  patient.  For  example,  in  sprains  of  the  ankle  the 
foot  should  be  at  right  angles  with  the  leg;  when  the  knee  is 
injured  the  joint  should  be  slightly  bent,  though  not  nearly  to 
the  degree  in  which  the  patient  is  almost  sure  to  place  it,  and 
the  arm  should  hang  by  the  side  when  the  shoulder  is  involved. 

The  pressure  must  be  applied  so  that  it  falls  only  on  the 
parts  that  require  it,  not  on  the  bony  prominences,  that  is  to 
say,  but  over  the  tendon  sheaths,  and  on  the  masses  of  soft 
and  delicate  tissue  that  fill  up  the  interspace  between  them 
and  the  bones,  especially  on  the  inner  side  of  the  limb.  It 
must  be  smooth,  even,  and  well  graduated,  commencing  from 
below,  and  working  upward  toward  the  trunk,  and  it  must 
possess  a  certain  amount  of  elasticity,  so  that  as  the  swelling 
diminishes  under  its  influence  the  bandage  may  still  keep  up 
some  degree  of  compression. 

For  this  purpose  there  is  nothing  more  suitable,  and,  fortu- 
nately, nothing  more  easily  obtained,  than  ordinary  cotton 
wool.  Pads  may  be  made  of  this  to  fit  into  any  depression, 
no  matter  how  small,  and,  if  not  too  firmly  compressed,  they 
keep  up  an  even  and  equable  amount  of  pressure,  even  when 
absorption  underneath  has  effected  a  considerable  difference 
in  the  size  of  the  limb.  Failing  this,  the  next  most  useful  sub- 


94  Sprains;  their  Consequences  and  Treatment. 

stance  is  a  firm  and  fine-textured  sponge.  This  may  be  made 
into  pads  which  admit  of  the  most  perfect  adjustment  as  re- 
gards size,  shape,  and  thickness,  and  it  is  more  easy  to  keep 
them  in  their  proper  place  when  the  limb  is  being-  bandaged. 
Many  other  substances,  however,  serve  on  special  occasions; 
dried  moss,  for  instance,  forms  a  capital  substitute,  and  I  have 
known  even  seaweed  tried  with  success.  Some  of  the  thicker 
and  softer  kinds  of  felt  make  admirable  pads,  firm  and  soft, 
yet  quite  elastic,  and  capable,  if  several  layers  are  sewn  to 
gether,  of  being  modeled  into  any  shape.  Sometimes  this 
firmness  is  of  especial  service.  I  have  employed  them  with 
great  advantage  in  sprains  of  the  extensor  tendons  on  the 
back  of  the  wrist,  when  the  distention  has  not  been  very  great, 
but  where  there  has  been  a  large  amount  of  creaking  or  grat- 
ing on  movement.  It  is  difficult  here  to  adjust  pads  of  cotton 
wool  sufficiently  accurately,  while  the  felt  is  easily  shaped  to 
suit  the  varying  thickness  of  the  soft  parts.  The  pressure  is 
distributed  evenly  over  the  whole  length;  the  tendons  are  kept 
at  rest ;  and  the  firm  compression  insures  the  rapid  disappear- 
ance of  the  exudation. 

Pads  of  sponge  or  felt  may,  moreover,  be  soaked  in  lotions, 
if  it  is  considered  advisable,  without  altogether  destroying 
their  elasticity.  I  have  not  found  much  occasion  to  put  this 
into  practice,  but  once  or  twice,  when  the  pain  over  small 
joints  was  very  severe,  the  application  of  a  lotion  containing 
a  solution  of  morphia  afforded  great  relief.  Of  course,  a  cer- 
tain amount  of  caution  must  be  used.  A  thick  felt  pad,  covered 
on  the  outer  side  with  a  layer  of  some  waterproof  material,  is 
capable  of  taking  up  no  inconsiderable  quantity,  but  the  area 
of  the  pad  is  generally  small,  and  the  condition  of  the  parts 
beneath  is  not  one  adapted  for  rapid  absorption.  If  there  is 
the  least  abrasion  this  caution  is  particularly  required. 

It  is  impossible  to  be  too  careful  in  molding  the  pads  to 
the  proper  shape  of  the  limb.  In  the  case  of  the  ankle,  for  ex- 
ample, where  the  joint  alone  is  involved,  the  swelling  shows 
itself  on  the  front,  lifting  up  the  tendons  that  run  down  to  the 
toes,  and  behind  on  either  side  of  the  tendo-Achillis,  filling  up 
the  natural  hollows  there,  and  reaching  up  the  leg  higher  on 
the  inner  side  than  the  outer.  Over  the  malleoli,  of  course, 
there  is  none,  and,  unless  the  injury  has  been  so  severe  as  to 
tear  the  ligaments,  scarcely  any  is  perceptible  along  their 


Sprains ;   their  Consequences  and  Treatment.  95 

lower  border.  This  may  be  complicated  by  the  distention  of 
some  or  all  of  the  tendon  sheaths  that  run  down  on  either  side; 
and  if  some  few  hours  have  been  allowed  to  pass  by,  there  is, 
in  addition,  a  great  deal  of  thickening-  in  the  loose  and  delicate 
tissue  that  fills  up  the  interstices  between  the  skin  and  the 
tendons,  and  the  tendons  and  the  bone.  The  swelling  may 
reach  down  far  on  to  the  foot,  and  almost  to  the  knee.  All 
this  must  be  made  out;  and  the  natural  contour  of  the  limb 
seen,  as  it  were,  through  the  swelling,  before  the  pads  can  be 
shaped  and  the  bandage  adjusted. 

Sometimes  pads  of  this  kind  may  be  made  to  serve  in  the 
place  of  splints.  In  the  knee,  for  example,  a  bandage,  as  usu- 
ally applied,  is  of  very  little  use;  nor  is  it  much  better  if  a 
horseshoe-shaped  cushion  is  adjusted  around  the  knee-cap. 
But  if  this  is  combined  with  a  firm  elastic  pad  of  felt  in  the 
popliteal  space  behind  (I  have  known,  when  nothing  else  could 
be  obtained  at  the  moment,  a  small  folded  pocket-handkerchief 
answer  admirably),  the  compression  is  spread  over  a  larger 
surface  of  the  joint,  better  resistance  is  given  for  the  bandage 
in  front,  and  an  admirable  splint  is  applied  to  the  knee  joint, 
keeping  it  nearly  straight,  and  possessing  the  great  advantage 
over  an  ordinary  back  splint  that  it  is  not  so  absolutely  and 
uncomfortably  rigid. 

Sometimes  it  is  one's  misfortune  to  meet  with  a  case  in 
which  the  limb  (generally  the  forearm)  seems  to  have  been 
sprained,  as  it  were,  all  round,  the  swelling  and  pain  are  so 
universal.  For  such  as  these  I  have  used  with  success  what 
may  be  considered  a  distant  imitation  of  Guerin's  treatment 
of  wounds ;  that,  at  least,  first  gave  me  the  idea.  The  limb  is 
to  be  well  padded  first,  according  to  the  anatomy  of  the  part, 
and  lightly  bandaged ;  then,  commencing  from  the  fingers,  be- 
tween which  small  cushions  are  placed,  it  must  be  wrapped  in 
sheet  after  sheet  of  cotton  wool  until  it  is  three  or  four  times 
the  natural  size ;  finally,  it  must  be  bandaged  from  below  up- 
ward as  firmly  as  possible.  If  the  cotton  wool  is  sufficiently 
thick  it  is  impossible  to  exert  too  much  pressure.  It  must  be 
admitted  that  the  application  is  exceedingly  hot;  but  it  cer- 
tainly relieves  pain ;  and  such  is  the  elastic  tension  of  the  wool, 
that  the  limb,  when  exposed  on  the  next  day,  is  almost  its 
natural  size.  The  comfort  is  greatly  increased  by  dusting  the 
limb  over  first  with  violet  powder. 


96  Sprains ;   their  Consequences  and  Treatment. 

Bandages  used  for  sprained  joints  need  not  be  of  any  special 
kind  so  long-  as  they  lie  evenly  and  smoothly  on  the  limb  and 
do  not  stretch.  India-rubber  ones,  or  those  made  of  woven 
elastic,  are  strongly  recommended  by  some;  but,  it  seems  to 
me,  without  adequate  reason.  They  keep  the  limb  very  hot ; 
the  solid  ones,  at  any  rate,  retain  the  perspiration  so  as  to  be 
sometimes  unpleasant;  and  it  is  very  difficult  to  apply  them 
sufficiently  firmly  without  making-  them  too  tight  and  con- 
verting them  into  a  species  of  torture.  While  the  limb  is  being 
bandaged  the  pads  may  be  secured  in  position  by  means  of 
common  elastic  bands  passed  round  the  limb,  an  excellent 
method  suggested  by'Dacre  Fox. 

Starch  bandages  and  other  fixed  appliances,  such  as  gum 
and  chalk,  plaster  of  Paris,  or  silicate  of  potash,  can  only  be 
recommended  under  special  conditions.  They  are  certain  to 
be  left  on  too  long,  and  that  is  a  fatal  objection.  Bandages,  as 
a  rule,  should  be  changed  every  day.  The  limb  no  doubt  feels 
fairly  comfortable  so  long  as  it  is  encased  and  kept  motionless. 
But  every  day  it  is  growing  more  and  more  stiff,  and  when  it 
is  released  the  least  attempt  at  movement  is  attended  by  pain. 
This  is  not  due  to  straining  or  tearing  of  the  union  between 
the  ends  of  the  torn  ligaments ;  no  strain  falls  on  it.  Ligaments 
may  be  tense,  but  they  are  not  stretched  unless  movement  is 
carried  beyond  what  is  natural,  which,  under  proper  manage- 
ment, never  should  happen.  It  cannot,  therefore,  be  due  to 
this.  In  reality  its  persistence  and  severity  are .  regulated 
more  by  the  amount  and  duration  of  the  swelling  than  by  any- 
thing else.  Of  course  if  ligaments  have  been  torn  from  bones, 
or  muscles  have  been  strained  or  lacerated,  the  skin  over  them 
is  tender  when  it  is  pressed  upon  or  tightly  stretched,  but  the 
pain  that  is  ordinarily  felt  when  a  sprained  joint  is  first  used 
is  scarcely  noticeable  if  exudation  is  prevented  and  passive 
motion  begun  early  enough.  Neither  of  these  conditions  is 
likely  to  be  carried  out  properly  if  the  limb  is  encased  in  a 
fixed  bandage. 

How  long  the  limb  should  be  bandaged  is  a  question  that 
can  hardly  be  answered  until  the  effects  produced  in  joints  by 
prolonged  inaction  have  been  taken  into  consideration. 


CHAPTER  VIII. 

TREATMENT.— REST. 

NOTHING  is  so  difficult  in  the  treatment  of  sprains  as  the 
question  of  rest —  how  long  the  joint  should  be  kept  quiet,  and 
when  the  patient  may  use  it  with  safety  as  he  likes.  It  is  the 
first  thing1  asked,  and  a  definite  time  is  usually  wanted  at 
once,  utterly  regardless  of  the  fact  that  it  is  impossible  to  re- 
turn more  than  a  general  answer  in  the  majority  of  instances. 
Each  case  must  be  judged  on  its  own  merits.  On  the  one 
hand,  if  the  joint  remains  long  unused,  there  is  the  possibility, 
almost  the  certainty,  of  its  becoming  stiff  and  crippled,  so  that 
it  is  years  before  it  regains  its  natural  freedom,  if  it  ever  does; 
on  the  other,  there  is  the  dread  of  exciting  inflammation,  and 
the  risk  of  reproducing  by  some  momentary  slip  the  whole  of 
the  original  mischief.  Between  these  it  is  necessary  to  hold 
a  middle  course;  leaning  too  much  to  either  side  inevitably 
brings  after  it  delayed  convalescence  in  some  form  or  other 
and  much  discredit. 

There  is  no  doubt  that  in  the  majority  of  cases  sprained 
joints  are  kept  at  rest  much  too  long.  It  is  imagined  that  if 
anything,  it  does  not  matter  what,  has  happened  to  a  joint,  it 
cannot  be  wrong  to  rest  it,  and  that  no  harm  can  possibly  fol- 
low from  its  being  kept  quiet.  The  dread  of  inflammation  is 
allowed  to  overshadow  everything  else.  It  is  forgotten  that 
the  function  of  a  joint  is  movement;  that  this  is  the  reason 
for  its  existence,  and  that  if  from  any  cause  it  is  kept  abso- 
lutely at  rest  it  loses  the  power  of  working,  just  as  an  eye  ac- 
customed to  long-continued  darkness  becomes  unable  to  bear 
the  light.  It  is  forgotten  that  prolonged  rest  does  produce 
changes,  and  very  definite  ones,  too,  in  the  structure  of  joints, 
even  when  they  are  healthy,  and  that  these  are  tenfold  more 
likely  to  occur  after  injury.  And  so  the  part  is  kept  perfectly 
quiet  until  it  becomes  stiff  and  rigid,  and  every  attempt  at 
movement  causes  pain. 


9$  Sprains ;   their  Conseqicenccs  and  Treatment. 

Effects  of  Prolonged  Rest  on  Healthy  Joints. — Some  of 
the  effects  stated  to  result  from  this  cause  are  of  a  very  strik- 
ing1 character.  Duverney  and  Petit  have  described  cases  in 
which  they  found  the  sy  no  vial  sac  and  the  spaces  round  it  enor- 
mously distended  with  a  serous  effusion ;  and  others  in  which 
there  were  adhesions  passing1  across  the  interior  from  one  bone 
to  the  other,  so  that  the  joint  was  almost  crippled.  Teissier  has 
given  an  account  of  one  in  which  the  adhesions  were  so  dense 
and  numerous  that  the  cavity  of  the  joint  was  entirely  oblit- 
erated, and  the  bones  so  tied  together  that  one  could  not  move 
in  the  least  upon  the  other.  In  others  he  found  the  synovial 
sac  distended  with  blood,  the  lining  membrane  thickened,  and 
more  vascular  than  natural,  and  the  inner  surface  coated  over 
with  a  recent  deposit  of  fibrinous  material,  which  was  rapidly 
being  organized  into  dense  unyielding  bands.  In  many  the 
cartilages  were  swollen  and  thickened  at  the  margin,  softened 
in  the  centre,  and  even  eroded  on  the  surface,  while  the  syno- 
vial fringes  were  almost  uniformly  converted  into  tough  fibrous 
bands  that  limited  the  fredom  of  the  joint  in  all  directions. 

Some  doubt,  it  is  true,  has  been  thrown  upon  his  explana- 
tion, owing  to  the  fact  that  in  all  the  cases  the  limb  had  been 
severely  hurt;  and  the  suggestion  has  been  offered  that  these 
changes  are  really  due  to  inflammation,  which  spread  from  the 
seat  of  injury  to  the  affected  joint;  but  it  is  admitted  that 
there  is  no  evidence  that  anything  of  the  kind  had  occurred. 
According  to  Teissier,  unbroken  rest  can  be  the  only  cause; 
and  in  this  he  is  strongty  supported  by  Bonnet  of  Lyons,  who 
came  to  the  same  conclusion  after  a  series  of  experiments  ex- 
pressly bearing  on  this  point.  It  is  admitted  that  the  position 
in  which  the  limb  is  retained  is  of  some  importance ;  that  some 
joints  are  more  liable  to  be  affected  in  this  way  than  others, 
those  farther  from  the  trunk  more  frequently  than  the  nearer 
ones,  the  fingers,  for  example,  more  often  than  the  wrist ;  and, 
further,  that  the  changes  are  most  conspicuous  in  the  aged, 
or  in  limbs  that  have  been  paralyzed;  but  the  main  fact  itself, 
according  to  them,  admits  of  no  dispute. 

Even  supposing  the  consequences  of  long  inaction  are  not 
so  extensive  as  this,  they  may  still  be  sufficiently  serious  to 
lead  to  grave  discomfort  and  suffering.  It  is  certain  that,  in 
old  people  at  any  rate,  a  rest  of  comparatively  short  duration 
is  enough  to  cause  great  stiffness,  especially  when  the  wrist 


Sprains ;  their  Consequences  and  Treatment.  99 

and  fingers  are  concerned.  These  show  the  effect  more  rapidy 
than  other  joints,  possibly  because  the  movements  they  exe- 
cute are  so  numerous  and  complicated;  even  in  a  few  days 
the  power  of  bending-  them  may  be  completely  lost ;  they  re- 
main rigidly  extended,  and  the  least  attempt  at  forcing  them, 
no  matter  how  gently  it  is  done,  gives  rise  to  severe  pain,  and 
meets  with  a  sense  of  resistance  which  is  not  due  to  muscular 
contraction. 

It  is  often  said  when  this  occurs  that  the  patients  are  gouty 
or  rheumatic,  and  that  the  stiffness  is  due  to  their  diathesis; 
but  there  is  no  evidence  of  it.  It  comes  on  without  aching  or 
pain,  that  is  not  felt  until  after  manipulation;  the  skin  is  not 
hot:  there  is  no  swelling  or  sign  of  inflammation;  the  onset  is 
imperceptible;  and  the  patient  is  unaware  of  anything  being 
wrong  until  the  hand  is  released  from  confinement  and  some 
attempt  made  to  move  it.  There  does  not  seem  any  other 
reason  possible  but  the  want  of  use  and  the  prolonged  rest  in 
the  straight  position. 

Changes  in  the  Tissues  Due  to  Prolonged  Rest. — When 
the  time  is  short  these  are  not  very  conspicuous.  There  is 
less  fluid  in  the  joint,  and  its  quality  sometimes  appears  to  be 
altered;  it  is  not  so  viscid  as  it  ought  to  be;  but  it  is  rare  to 
find  anything  more.  The  tissues  themselves  do  not  seem  to 
be  affected  as  they  are  at  a  later  period,  and  recovery  is  gen- 
erally rapid.  Afterwards  there  are  other  alterations;  the  loose 
and  delicate  connective  tissue  that  fills  up  all  the  irregularities 
and  interspaces  becomes  affected.  In  some  parts  it  is  com- 
pressed until  it  becomes  dense  and  hard ;  in  others  it  is  filled 
with  fluid,  and  becomes  soft  and  pulpy.  Then,  as  the  bones 
and  muscles  move,  and  the  pressure  shifts  from  one  point  to 
another,  the  uneven  tension  causes  pain.  Instead  of  the  tissues 
yielding  smoothly  and  evenly,  accommodating  themselves  to 
each  other  so  that  no  unfair  pressure  falls  on  any  part,  some 
are  hard  and  resistant,  having  completely  lost  their  flexibility ; 
others  are  swollen  and  distended,  so  that  they  cannot  give 
way.  The  effect,  if  force  is  used,  is  much  the  same  as  when  a 
ligament  or  any  other  band  of  connective  tissue  is  stretched 
beyond  its  natural  limit;  the  part  swells  up  and  becomes  pain- 
ful; the  temperature  rises;  and  if  the  attempt  is  repeated 
sufficiently  often,  the  changes  become  more  and  more  marked 
until  they  insensibly  pass  into  inflammation. 


ioo  Sprains ;   their  Consequences  and  Treatment. 

In  some  of  the  older  cases  the  results  are  even  more  serious. 
The  capsule  shrinks,  and  becomes  rigid;  or,  owing-  to  the  re- 
laxation of  the  muscles,  loses  its  tone,  and  is  unduly  stretched ; 
the  secretion  of  the  sy  no  vial  membrane  is  completely  altered ; 
the  softened  parts  in  the  tissues,  where  there  has  been  no 
pressure,  become,  as  it  were,  accustomed  to  the  increase  in 
the  size  of  the  space  in  which  they  lie,  and  fill  it  up  entirely ; 
those,  on  the  other  hand,  that  have  been  compressed,  waste 
away,  so  that  when  the  two  surfaces  of  the  joint  are  moved 
apart  there  is  nothing  to  fill  up  the  interval,  unless  the  sur- 
rounding tissues  are  crushed  in  by  outside  pressure.  The  car- 
tilages grow  thinner  and  thinner;  the  ligaments  shorten,  and 
hold  the  bones  in  rigid  apposition;  the  muscles  degenerate, 
and,  accommodating  themselves  to  the  fixed  length  at  which 
they  are  kept,  either  contract  and  become  converted  into  a 
kind  of  fibroid  tissue,  or  waste  and  stretch.  The  tendons,  too, 
at  length  become  glued  to  their  sheaths,  and  refuse  to  move; 
the  skin  loses  its  elasticity  and  suppleness;  there  is  a  blue 
congested  look  about  it ;  it  does  not  move  freely  or  easily  over 
the  structures  beneath,  but  seems  shrunken  on  to  the  bones, 
as  if  it  were  too  tight,  and  all  the  soft  tissue  underneath  had 
gone.  Even  the  bones  waste,  and  become  so  thinned  that  a 
comparatively  slight  degree  of  violence  may  cause  them  to 
give  way. 

In  the  Fingers  and  Ankle. — This  may  happen  when  the 
joints  are  perfectly  healthy  in  all  other  respects.  The  fingers 
have  been  already  mentioned.  There  is  scarcely  a  fracture  of 
the  arm  or  forearm  in  which  a  certain  amount  of  stiffness  is 
not  left  afterwards.  It  is  not  that  they  have  been  hurt  in  any 
way ;  they  have  merely  been  kept  confined  in  a  straight  posi- 
tion, under  pressure,  without  being  allowed  to  move,  and  when 
released  they  are  found  to  be  stiff  and  rigid.  The  same  thing- 
occurs  in  the  ankle  joint  when  a  patient  is  confined  to  bed  dur- 
ing the  course  of  a  prolonged  or  exhausting  illness.  The  foot 
is  kept  constantly  pressed  down  by  the  weight  of  the  bed- 
clothes into  the  same  straight  line  as  the  leg,  and  at  last  be- 
comes fixed  in  that  position ;  the  muscles  on  the  back  of  the 
leg  become  rigid  and  shortened ;  the  ligaments  on  the  front  of 
the  joint  are  elongated  and  stretched;  and  when  the  patient 
begins  to  get  about  he  finds  that  he  is  unable  to  place  the  sole 
of  the  foot  flat  upon  the  ground,  and,  not  unfrequently,  is  com- 


Sprains ;  their  Consequences  and  Treatment.  101 

peled  to  undergo  a  long-  and  tedious  course  of  treatment  before 
the  displacement  can  be  rectified. 

Not  the  Eesult  of  Injury  or  Inflammation. — It  is  quite 
true  that  this  condition  is  more  common  after  injuries  than 
anything-  else;  but  it  must  be  recollected  that  they  are  by  far 
the  most  frequent  cause  of  confinement  in  one  position.  It 
certainly  may  occur  independently  of  them,  as  well  as  of  in- 
flammation; and  it  cannot  be  considered  a  peculiarity  of  old 
age,  for  though  it  is  more  often  met  with  in  people  who  have 
passed  middla  life,  slight  degrees  of  it,  sufficiently  severe  to 
cause  considerable  inconvenience,  though  they  yield  more 
readily  to  treatment,  may  be  found  in  all  periods.  • 

Faulty  Position. — Malgaigne  has  offered  the  suggestion 
that  stiffening  of  joints  from  rest  alone  is  due  not  so  much  to 
confinement  in  one  position  (for  then  it  would  be  more  common 
even  than  it  is  in  cases  of  fracture),  but  to  the  fact  that  the 
position  is  unsuitable,  and,  therefore,  hurtful.  In  his  opinion, 
unbroken  rest,  combined  with  extension  in  the  straight  line,  is 
the  immediate  cause.  The  natural  position  of  repose,  in  which 
the  ligaments  are  relaxed,  lies  between  the  extremes  of  flexion 
and  extension;  if  a  joint  is  kept  for  any  length  of  time  rigidly 
straight  some  of  the  ligaments  are  loose,  others  are  in  a  state 
of  constant  tension.  The  former  gradually  shorten,  and  be- 
come rigid  and  unyielding;  the  latter  stretch,  and  grow  weaker 
and  weaker,  or  even  at  last  become  inflamed,  owing  to  the  un- 
natural condition  in  which  they  are  maintained.  In  either 
case,  the  suppleness  and  flexibility  are  lost,  and  when  an 
attempt  is  made  to  move  the  joint,  pain  is  caused  owing  to 
the  fact  that  the  tension  falls  unfairly  on  them. 

It  is  not  unlikely  that  this  is  correct  in  the  main,  and  that 
if  a  joint  is  perfectly  healthy  there  is  not  much  fear  of  its  be- 
coming stiff,  unless  the  limb  is  kept  in  such  a  position  that  un- 
fair traction  is  maintained  continuously  on  ligaments  which 
are  not  suited  to  resist  it.  The  important  fact  is  that  it  may 
occur — indeed,  that  in  some  circumstances  it  will  occur — even 
when  a  joint  is  absolutely  sound.  If  it  has  been  sprained,  if 
the  ligaments  and  the  capsule  are  softened  by  exudation,  and 
by  the  changes  in  the  circulation  that  of  necessity  take  place 
after  injuries,  continued  rest  is  almost  certain  to  produce  it  in 
a  very  severe  form.  The  length  of  time  need  not  be  great; 
very  few  days  are  sufficient;  and  the  actual  alteration  in 


RT/no?5Tc  533JJOO 

IDrtU.^  -    :i1  . 1.OK-VHH 

102  Sprains ;  their  Consequences  and  Treatment. 

structure  need  not  be  of  great  extent;  a  fold  of  the  capsule 
may  be  thickened,  or  some  of  the  synovial  fringes  matted  to- 
gether, or  there  may  be  merely  some  induration  in  the  soft 
tissues,  or  filling  up  of  the  bursal  spaces  on  the  outside  of  the 
joint,  a  state  of  things  that  may  be  produced  in  a  few  days  at 
the  most;  it  is  quite  enough  to  prevent  the  free  action  of  the 
joint  and  to  give  rise  to  severe  pain  if  the  attempt  is  carried 
too  far. 

In  the  majority  of  instances  joints  that  continue  stiff  and 
crippled  for  such  a  length  of  time  after  being  sprained  show 
nothing  more  than  this,  and  it  does  not  appear  to  be  much. 
There  is  no  heat  or  redness  of  skin;  the  swelling  is  only  such 
as  would  be  accounted  for  by  the  extravasation  of  blood  at  the 
time,  and  the  amount  of  exudation  that  is  needed  for  repair 
afterward;  there  is  none  of  that  throbbing,  burning  pain 
which  can  rarely  be  mistaken;  and  there  is  no  sign  of  inflam- 
mation. The  reason  that  makes  it  so  serious  is,  that  when 
once  this  condition  is  set  up,  unless  proper  steps  are  taken  to 
prevent  it,  there  is  a  constant  tendency  for  it  to  grow  worse 
and  worse.  The  adhesions  and  contractions  that  develop  dur- 
ing prolonged  immobility  cause  the  softer  and  more  delicate 
structures  to  be  strained  and  bruised  whenever  an  attempt  at 
movement  is  made.  Probably,  if  they  are  forced  to  give  way 
once  for  all,  the  good  that  is  done  far  exceeds  the  harm ;  but 
this  rarely  happens.  Much  more  often  either  the  sufferer  does 
not  move  the  joint  at  all,  so  that  it  is  kept  rigid  longer  still, 
or,  if  he  has  sufficient  fortitude  to  persevere,  makes  matters 
worse  by  half  measures.  The  shortened  structures  are  merely 
stretched  and  strained,  the  part  becomes  swollen  again,  a 
fresh  amount  of  exudation  is  thrown  out,  the  adhesions  grow 
thicker  and  stronger,  and  the  joint  is  doomed  to  a  further 
course  of  rest  under  the  impression  that  it  is  inflamed. 

Movement  and  Inflammation. — On  the  other  hand  it  is 
urged,  even  by  those  who  admit  that  inflammation  is  not  an 
absolutely  necessary  consequence,  that  it  is  almost  certain  to 
be  produced  if  the  part  is  moved  too  freely  or  is  used  too  soon. 
They  agree  that,  unless  there  are  other  causes  at  work,  sprains 
are  not  more  likely  to  set  up  an  attack  of  inflammation  than 
simple  fracture  or  any  other  form  of  subcutaneous  injury;  but 
they  insist  that  it  is  absolutely  necessary  to  keep  the  part  at 
rest  for  fear  of  its  setting  in.  It  seems  to  me,  however,  that  in 


Sprains ;  their  Consequences  and  Treatment.  103 

laying-  down  a  rule  of  this  kind  it  is  advisable  to  be  more  pre- 
cise with  regard  to  the  extent  and  character  of  the  movements 
executed,  and  the  object  with  which  they  are  performed.  The 
danger  of  inflammation  does  not  arise  from  slowly  and  care- 
fully moving  an  injured  joint  once  or  twice  a  day;  the  liability 
to  its  occurrence  is  not  increased  in  the  least  by  this.  An 
attack  may  be  brought  on  by  some  peculiarity  of  constitution, 
such  as  gout  or  rheumatism,  or  by  some  morbid  condition  of 
the  blood,  inherited  or  accidental ;  or  it  may  be  caused  by  ten- 
sion if  blood  or  any  other  fluid  is  allowed  to  collect  unchecked 
in  the  synovial  spaces  or  the  tissues  round ;  but  it  is  scarcely 
possible  to  imagine  that,  once  or  twice  in  the  course  of  a  day, 
slowly  and  firmly  straightening  out  a  joint  that  has  been 
sprained  could  produce  any  such  result. 

It  is  not  intended  for  a  moment  that  anj'one  should  be 
allowed  to  do  what  he  pleases  with  his  limb.  There  is  a  popu- 
lar idea  that  injuries  of  this  kind  can  be  walked  off,  that  only 
provided  the  joint  is  not  allowed  to  rest  for  some  considerable 
time  no  ill  result  will  follow;  and  there  are  always  to  be  found 
people  ready  to  declare  that  they  themselves  have  done  it  time 
after  time  without  hurt  of  any  kind,  and  that  they  have  re- 
covered more  quickly  in  consequence.  Sprains  that  admit  of 
being  cured  in  this  way  can  clearly  be  only  of  the  very  slightest 
description;  for  such  as  these  it  may  answer  well  enough,  but 
it  would  scarcely  be  advisable  to  try  it  where  the  tissues  have 
been  seriously  injured,  or  where  the  swelling  and  extravasa- 
tion are  of  any  extent.  It  is  impossible  to  imagine  that  the 
repair  of  a  ligament  that  has  been  torn  in  two  or  wrenched 
from'  its  point  of  attachment  to  the  bone  can  be  assisted  by 
such  a  proceeding.  It  may  be  of  service  where  the  strain  has 
fallen  on  the  muscles  only  and  has  not  been  sufficiently  severe 
to  tear  any  of  their  fibres,  or  where  the  effusion  is  limited  to 
some  of  the  muscular  interspaces  outside  the  joint;  in  others 
it  is-  a  method  of  cure  which  is  only  too  likely  to  end  in  disaster. 

Passive  Movement. — It  by  no  means  follows,  however,  that 
the  extreme  opposite  course  should  be  adopted  and  the  limb 
maintained  in  a  state  of  absolute  immobility.  It  is  quite  pos- 
sible to  move  a  sprained  joint  sufficiently  to  prevent  the  oc- 
currence of  stiffness  or  the  formation  of  adhesions  without 
causing  the  least  pain  or  suspicion  of  inflammation.  The  first 
thing  is  to  check  the  swelling  of  the  part;  if  this  can  be  pre- 


IO4  Sprains ;   their  Consequences  and  Treatment. 

vented  passive  movement  may  be  carried  out  with  no  more 
than  a  sense  of  inconvenience.  The  pain,  throbbing,  and  risk  of 
inflammation  are  due  to  the  distention  of  the  joint  and  tissues 
round,  and  to  the  continued  traction  exerted  on  the  nerves.  If 
this  is  stopped  at  the  first  the  joint  may  be  quietly,  but  firmly, 
flexed  and  extended  without  causing  anything  deserving  the 
name  of  suffering,  and  without  any  fear  of  reproducing  the 
original  accident. 

Movement  undertaken  with  this  object  must  be  passive, 
not  carried  out  by  the  patient.  Active  movements  are  effected 
by  the  contraction  of  the  muscles,  acting  in  their  ordinary 
course,  and  are  executed  for  some  purpose,  or  in  opposition  to 
some  resisting  power;  passive  ones,  on  the  other  hand,  are 
carried  out  by  some  other  force,  as  when  one  person  bends  and 
extends  the  limbs  of  another  who  exerts  no  strength  himself; 
or  when  the  finger  joints  of  one  hand  are  worked  by  means  of 
the  other.  The  bones  are  moved  one  on  the  other;  the  tendons 
play  backward  and  forward  in  their  sheaths ;  the  folds  of  the 
synovial  membrane  and  of  the  capsule  are  alternately 
straightened  out  and  compressed ;  the  pressure  points  in  the 
tissues  are  shifted  as  they  are  in  normal  action ;  and,  what  is 
especially  important  for  maintaining  their  vigor,  a  certain 
amount  of  traction  is  put  upon  the  muscles  and  nerves;  but 
no  work  is  done.  The  joints  are  treated  as  complicated  pieces 
of  machinery,  each  part  of  which  is  moved  by  some  external 
force,  in  a  direction,  and  with  a  range,  that  can  be  limited  with 
the  greatest  nicety.  If  one  of  the  restraining  ligaments  is 
torn  or  hurt,  no  stress  need  fall  on  it ;  if  the  soft  tissues  on  one 
side  are  bruised,  they  need  not  be  pressed  upon;  and  if  a 
muscle  has  been  ruptured,  its  ends  are  not  more  widely  sepa- 
rated from  each  other.  Everything  can  be  regulated  with  the 
greatest  accuracy. 

Time  for  Movement. — The  sooner  this  is  begun  the  better. 
It  is  very  rare  for  the  tissues  on  both  sides  of  a  joint  to  suffer 
to  the  same  extent.  Those  on  one  aspect  may  be  torn,  those 
on  the  other  bruised,  from  the  way  in  which  they  are  crushed 
together  when  it  is  twisted;  but  the  latter  recover  long  before 
the  former,  and  are  capable  of  carrying  out  all  their  ordinary 
work  at  a  time  when  a  comparatively  slight  strain  would  tear 
the  others  in  two  again.  As  a  rule,  passive  movement  may 
be  commenced  from  the  second  day  with  the  certainty  of  pre- 


Sprains ;  their  Consequences  and  Treatment.  105 

venting-  adhesions,  and  without  the  least  fear;  it  can  be  regu- 
lated much  too  well  to  allow  any  tension  to  fall  on  the  injured 
part. 

This  answers  especially  well  when  the  ligaments  have  suf- 
fered most.  As  a  rule,  these  structures  cannot  stretch ;  their 
function  is  solely  to  prevent  movement  being"  excessive  or  pass- 
ing some  definite  limit.  So  long"  as  the  range  of  action  is  kept 
within  its  normal  bounds  no  strain  falls  on  them;  they  are 
merely  straightened  out  or  unfolded,  as  it  were.  When  a  joint 
is  sprained  the  movement  is  carried  beyond  this,  and  the  liga- 
ments, unless  they  are  strong-  enoug-h  to  resist  the  momentum, 
yield  and  give  way;  but  even  after  this  has  happened,  if  the 
part  is  prevented  from  swelling,  it  may  be  made  to  execute  all 
ordinary  movements  without  fear  of  hurt,  provided  it  is 
handled  carefully  by  one  who  knows  how  much  may  be  done. 

It  need  not  be  said  that  hap-hazard  or  careless  movements 
must  be  absolutely  forbidden.  The  most  accurate  diagnosis 
is  necessary  to  make  certain  what  structures  have  suffered 
and  what  have  not;  and  there  must  be  a  thorough  and  exact 
acquaintance  with  the  action  of  the  joint,  so  that  the  right 
kind  and  right  degree  of  movement  may  be  selected;  but  pro- 
vided this  is  done  there  is  no  reason  why  the  joint  should  not 
be  worked  in  this  way  from  the  very  first.  If  it  is  carried  out 
thoroughly  adhesions  cannot  form. 

If  a  tendon  has  been  dislocated,  and  the  sheath  of  fibrous 
tissue  which  maintains  it  in  its  groove  torn  open,  or  if  one  of 
the  cartilaginous  discs  which  exist  in  some  joints,  such  as  the 
knee,  has  been  displaced,  the  part  may  be  exercised  without 
fear  of  reproducing  the  dislocation  or  of  delaying  the  union  of 
torn  fibres.  In  the  ankle,  for  example,  it  is  not  uncommon  for 
the  tendons  on  the  outer  side  to  be  displaced  forward  on  to 
the  bone.  They  are,  ordinarily  speaking,  held  firmly  down  by 
a  fibrous  sheath  thrown  over  them,  and  lined  with  a  delicate 
synovial  membrane;  sometimes  this  is  torn,  and  the  tendon 
escapes  from  its  bed.  When  this  has  once  taken  place  a  single 
incautious  movement  on  the  part  of  the  patient,  before  the 
sheath  has  had  time  to  repair  itself,  may  tear  it  open  again 
and  reproduce  the  dislocation;  and  if  this  happens  more  than 
once  it  is  not  improbable  that  repair  never  will  be  carried  out ; 
that  the  sheath  will  remain  loose  and  yielding,  allowing  the 
tendons  to  slip  backward  and  forward  with  the  slightest 


io6  Sprains ;  their  Consequences  and  Treatment. 

twist  until  the  use  of  the  corresponding1  muscles  is  practically 
lost.  But  if  passive  motion  is  employed  systematically  and 
carefully  by  some  other  person,  who  knows  what  the  injury  is, 
and  how  best  its  ill-effects  may  be  avoided,  the  joint  may  be 
exercised  thoroughly,  flexed  and  extended  as  far  as  is  desirable, 
and  the  nutrition  of  the  muscles  permanently  maintained  with- 
out the  least  fear  of  this  untoward  complication. 

Even  in  the  most  severe  sprains,  when  the  staining-  due  to 
the  extravasated  blood  reaches,  as  it  often  does,  nearly  up  to 
the  knee-joint,  it  is  advisable  to  begin  on  the  second,  or,  at  the 
very  latest,  on  the  third  day.  All  that  is  necessary  is  that 
the  whole  of  the  swelling-  should  have  been  dispersed  by  care- 
ful bandaging-,  or  by  other  means.  The  foot  is  then  to  be  re- 
leased from  all  constraint,  the  skin  and  the  subcutaneous  tis- 
sues thoroughly  kneaded,  and  the  joint  quietly,  but  firmly, 
flexed  and  extended  several  times  as  far  as  it  is  ordinarily  in 
walking.  This  should  be  repeated  every  day  until  recovery  is 
perfect,  the  limb  in  the  meantime  being  as  carefully  and 
methodically  bandaged  as  it  was  at  first. 

At  first,  no  doubt,  there  is  considerable  apprehension  on 
the  part  of  the  patient,  and  probably  the  muscles  are  uncon- 
sciously kept  rigid  and  resisting;  but  this  is  easily  overcome 
by  kneading  and  steady,  gentle  pressure.  Gradually,  as  the 
fear  of  being  hurt  diminishes,  the  movements  become  more  and 
more  free  until  all  that  is  wished  can  be  executed  without  dis- 
tress. Pain  ought  scarcety  to  be  felt.  Of  course,  if  a  ligament 
has  been  torn  off  the  bone,  and  direct  pressure  is  exerted  on 
the  spot,  it  is  felt  acutely;  but  these  are  the  places  that  should 
be  carefully  avoided,  especially  at  first.  After  a  little  manip- 
ulation the  tenderness  generally  diminishes  considerably.  If 
the  swelling  has  been  thoroughly  dispersed,  so  that  there  is 
no  tension  on  any  part  of  the  capsule  or  the  tissues  round,  and 
if  care  is  taken  not  to  move  the  joint,  so  far  as  to  put  undue 
strain  on  a  ligament  that  has  been  stretched  or  torn,  the 
nerves  are  not  dragged  upon  or  compressed,  and  the  move- 
ment is  practically  painless. 

The  ankle  joint,  owing  to  the  plan  of  its  construction,  is 
peculiarly  well  suited  to  this  method  of  treatment.  Sprains 
are  nearly  always  caused  by  the  foot  being  suddenly  twisted 
to  one  side  or  the  other,  so  that  the  greatest  strain  falls  on 
ligaments,  which  in  all  ordinary  movements,  are  only  moder- 


Sprains ;  their  Consequences  and  Treatment.  107 

ately  tight.  The  slightest  attempt  at  bending  the  foot  later- 
ally, in  the  direction  of  the  original  twist,  causes  the  most  in- 
tense pain,  and  all  the  muscles  round  become  involuntarily 
rigid.  All  ordinary  movements,  on  the  other  hand,  are  allowed 
to  take  place  from  the  first,  without  the  least  resistance,  after 
the  natural  feeling  of  apprehension  has  been  overcome. 

I  have  repeatedly  seen  the  most  severe  cases  treated  in  this 
way  recover  so  completely  in  the  course  of  a  few  days,  that, 
unless  there  was  an  exceptional  amount  of  walking  to  be  done, 
the  patient  could  follow  his  ordinary  occupation  without  danger 
and  without  pain.  Of  course,  if  a  ligament  is  torn  across,  a 
certain  amount  of  time  is  required  before  it  can  unite,  and  still 
more  before  it  can  be  firm;  but  the  position  in  which  the 
structures  are  placed  by  this  plan  is  unquestionably  the  most 
favorable  for  speedy  recovery.  The  ends  lie  in  close  apposi- 
tion to  each  other;  no  external  force  is  allowed  to  separate 
them,  and,  what  is  much  more  important,  the  synovial  cavity 
of  the  joint  is  not  allowed  to  remain  distended  with  fluid,  keep- 
ing the  torn  surfaces  continually  apart.  If  this  is  carried  out 
fairly  and  consistently  from  the  commencement,  it  is  impossi- 
ble for  the  joint  to  become  stiff.  Adhesions  between  contiguous 
surfaces  are  effectually  prevented  by  the  passive  motion.  The 
free  manipulation  renders  any  rigidity  or  contraction  of  the 
capsule  impossible.  Unless  there  is  some  other  predisposing  in- 
fluence, inflammation  is  equally  out  of  the  question.  There  is  no 
tension  to  excite  it,  and,  if  the  compression  is  properly  carried 
out,  there  can  be  no  dilatation  of  the  blood-vessels  to  pave  the 
way  for  it;  nor  need  there  be  any  fear  that  afterward  there 
will  be  that  peculiar  sense  of  weakness  and  insecurity  which 
is  so  common  as  a  consequence  of  sprains.  In  by  far  the  ma- 
jority of  instances  this  is  due  to  distention  of  the  capsule  or 
yielding  of  the  ligaments ;  or,  when  this  does  not  occur,  to  the 
fact  that  the  muscles,  from  being  so  long  unused,  have  become 
stiff  or  rigid,  and  do  not  respond  as  actively  or  as  vigorously 
as  they  ought. 


OHAPTEE  IX. 

FORCIBLE  MANIPULATION. 

FEW  modes  of  treatment  have  had  a  more  curious  history 
than  forcible  manipulation  as  applied  to  stiff  joints.  Often,  for 
years  together,  in  the  greatest  disfavor,  owing-,  it  must  be 
admitted,  to  indiscriminate  application,  and  almost  discarded, 
it  has  always  managed  to  retain  a  foothold  in  some  part  or 
other;  and  every  now  and  then,  when  its  mishaps  have  been 
forgotten,  has  sprung  up  again  into  notoriety,  under,  perhaps, 
some  change  of  name.  Very  few  minor  operations  are  capa- 
ble of  giving  such  instantaneous  and  striking  relief.  It  often 
happens  that,  as  a  result  of  some  simple  manipulation,  a  joint 
that  has  been  crippled  and  the  seat  of  pain  for  weeks  and 
weeks  is  suddenly  and  completely  released ;  but,  at  the  same 
time,  it  must  be  remembered  that,  unless  proper  care  is  taken 
in  the  selection  of  cases,  very  few  operations  can  do  more 
harm,  and  also  that  it  is  not  always  easy  to  lay  down  rules  by 
which  the  choice  is  to  be  guided. 

Adhesions  must  be  Divided  or  Torn. — If  a  joint  is  stiff  and 
rigid  from  shortening  in  the  fibrous  tissue  round  it,  there  is 
only  one  thing  to  be  done,  only  one  plan  of  treatment  that 
holds  out  a  reasonable  prospect  of  success:  the  contracted 
tissue  must  be  either  divided  or  stretched.  Nothing  else  is  of 
any  avail.  Baths,  whether  hot,  or  cold,  or  douche ;  galvanism, 
massage,  friction,  counter-irritation,  blistering,  and  the  num- 
berless other  remedies  so  often  employed,  are  of  little  or  no 
service.  It  is  true  that  the  circulation  and  nutrition  of  the 
part  improve  under  their  use ;  the  muscles  recover  their  tone 
and  firmness;  the  skin  becomes  more  healthy  in  appearance, 
and  the  general  aspect  of  the  joint  is  altogether  different;  but 
if,  when  the  muscles  were  relaxed,  the  movements  were  stiff 
and  constrained,  they  will  continue  in  this  condition,  no  matter 
how  energetically  these  methods  are  carried  out.  They  are 


Sprains :   their  Consequences  and  Treatment.  109 

necessary  as  accessories;  in  fact,  they  are  almost  indispensa- 
ble as  a  means  for  educating-  the  muscles  and  nerves,  so  that 
they  can  exert  their  power  again  as  soon  as  freedom  of  move- 
ment has  become  possible;  but  of  themselves  they  can  do  little 
or  nothing-  toward  g-etting  rid  of  the  stiffness  when  there  is 
the  least  degree  of  change  in  the  fibrous  tissue. 

This  has  been  learnt  by  dint  of  experience  of  the  roughest 
kind.  The  strange  idea  that  sprains  are  nearly  always  fol- 
lowed by  inflammation  (though  it  is  admitted  that  it  rarely 
results  from  any  other  form  of  subcutaneous  injury),  and  the 
dread  of  causing  a  fresh  outbreak  by  rough  handling,  have,  to 
a  great  extent,  deterred  those  who  felt  the  responsibility  from 
adopting  more  active  measures.  At  least,  this  seems  to  be 
the  most  reasonable  explanation  of  the  fact  that,  at  the  present 
day,  though  means  for  making  an  accurate  diagnosis  are  so 
much  better  than  they  were,  and  though  it  is  so  easy  to  avoid 
the  infliction  of  pain,  so  little  is  accomplished  by  this  method, 
and  so  many  people  are  content  to  get  about,  as  best  they  can, 
with  joints  which,  at  the  most,  have  only  partially  recovered. 
Even  then  it  is  not  easy  to  understand  why  there  should  be 
such  objection.  Supposing  for  an  instant  that  inflammation 
were  a  much  more  common  consequence  of  sprains  than  it 
really  is,  it  is  very  unlikely  that  an  attack  would  be  caused 
by  moving  a  stiffened  joint  within  its  natural  limits,  especially 
when  every  precaution  is  being  taken  to  prevent  its  occur- 
rence. The  popular  treatment  is  absolute  rest;  but  though 
this,  as  already  mentioned,  is  necessary  under  certain  condi- 
tions, it  must  always  be  remembered  that  a  joint  can  never 
become  healthy  so  long  as  it  remains  unused. 

Division. — Of  the  two  methods  I  have  mentioned,  the  first, 
division,  is  very  rarely  required  in  the  case  of  simple  sprains. 
Sometimes,  it  is  true,  the  muscles  on  one  side  of  a  limb  become 
so  hard  and  rigid  from  long  disuse  that  they  refuse  to  yield  to 
any  reasonable  amount  of  force,  and  then  something  of  the 
kind  must  be  done;  but  this  is  not  common.  It  may  occur  in 
the  ankle,  when  a  patient  has  been  for  some  time  confined  to 
bed,  with  the  wreight  of  the  clothes  resting  on  the  front  of  the 
foot,  constantly  pressing  it  into  the  same  straight  line  with  the 
leg.  When  this  happens,  the  muscles  at  the  back  of  the  calf 
grow  more  and  more  rigid,  until,  if  proper  steps  are  not  taken 
to  prevent  it,  they  become  permanently  contracted.  If  an 


no  Sprains;  their  Consequences  and  Treatment. 

attempt  is  made  to  move  the  joint  against  them,  it  feels  as  if 
two  bony  surfaces  were  being  driven  against  each  other;  it 
does  not  yield  in  the  least;  the  foot  is  hopelessly  fixed,  and 
there  is  no  alternative  but  to  divide  the  tendon. 

Structures  that  require  division  are  rarely  situated  close 
to  a  joint.  As  a  rule,  they  have  little  or  nothing  to  do  with  its 
synovial  lining,  or  even  with  the  loose  fibrous  tissue  outside 
the  capsule.  For  the  most  part  they  are  attached  to  distant 
points,  and  are  either  thickened  portions  of  the  fascia,  which 
have  undergone  passive  contraction,  or  tendons  of  muscles 
shortened  from  disuse.  These  have  to  be  divided  before  any 
thing  further  can  be  done;  but  though  this  is  not  unusual  after 
a  joint  has  been  inflamed,  it  is  rare  to  find  such  extensive 
changes  after  mere  sprains.  In  any  case  it  is  necessary  to 
examine  the  limb  thoroughly  beforehand  while  the  patient  is 
under  an  anaesthetic.  It  very  commonly  happens  that  what 
is  apparently  absolute  rigidity  disappears  at  once  when  the 
muscles  are  relaxed. 

When  division  is  required  it  must  be  carried  out  in  accord- 
ance with  the  ordinary  rules  of  tenotomy.  A  preliminary 
course  of  kneading  is  frequently  of  great  benefit;  it  loosens 
the  subcutaneous  tissue,  and  makes  the  skin  more  supple  and 
yielding;  but  care  must  be  taken  to  give  the  part  a  complete 
rest  for  at  least  two  days  before.  The  fewer  the  number  of 
punctures,  and  the  smaller  the  size,  the  better,  so  long  as  it  is 
done  thoroughly.  Very  often,  after  beginning,  it  is  found  that, 
independently  of  the  superficial  bands,  there  are  deeper  ones 
beneath,  the  presence  of  which  could  not  be  ascertained  before; 
whenever  it  is  safe,  they  must  be  treated  in  the  same  manner. 
In  all  cases  the  punctures  must  be  allowed  to  heal  before  the 
least  degree  of  extension  or  manipulation  is  attempted,  for 
fear  of  tearing  the  skin,  as  this  is  often  exceedingly  thin  over 
such  parts.  In  general,  four  or  five  days  are  sufficient.  Then, 
if  firm  pressure  is  made  with  the  thumb  over  the  point  of  sec- 
tion, while  the  part  is  being  manipulated,  the  newly-formed 
fibrous  tissue  between  the  deeper  structures  is  easily  made  to 
yield  without  fear  of  injury  to  the  rest.  Failure  of  union,  when 
a  tendon  or  a  band  of  fascia  is  divided  in  only  one  place,  is 
quite  exceptional. 

Manipulation. — Manipulation  is  much  more  useful  than 
division;  it  can  be  employed  for  such  a  variety  of  purposes.  In 


Sprains ;   tJieir  Consequences  and  Treatment .  1 1 1 

the  early  stages  it  prevents  the  occurrence  of  stiffness  or  the 
formation  of  adhesions.  Later,  when  the  swelling-  and  heat 
have  disappeared,  it  is  no  less  successful  in  restoring-  freedom 
and  ease  of  movement,  and  afterward,  when  all  mechanical 
obstructions  have  been  cleared  away  by  its  use,  it  is  one  of  the 
most  effectual  methods  known  for  bringing  back  the  circula- 
tion and  nutrition  of  the  part,  and  giving  again  to  the  muscles 
and  nerves  the  energy  which  has  so  long  been  wanting. 

When  the  object  is  to  set  free  a  stiffened  joint,  it  may  be 
applied  in  one  of  two  ways.  The  first  aims  at  breaking  down 
all  obstacles  at  once  by  a  few  vigorous  but  well-directed  move- 
ments; the  second  merely  attempts  to  stretch  the  contracted 
tissues,  little  by  little  each  day  until  they  cease  to  act  any 
longer  as  an  obstruction.  The  principle  is  quite  distinct.  Each 
plan  has  its  own  advocates,  but  it  is  especially  urged  against 
the  former  that  it  is  a  rough  and  bap-hazard  method  of  pro- 
ceeding, likely  to  excite  inflammation,  and  always  liable  to  do 
more  harm  than  good. 

Rapid. — In  certain  cases  no  doubt  this  may  occur.  There 
are  plenty  of  instances  on  record  in  which  limbs,  and  even 
lives,  have  been  lost  by  reckless  manipulation.  But  this  is 
entirely  due  to  the  fact  that  the  cases  were  unsuitable,  and 
that  sufficient  precautions  were  not  taken.1  When  carried 
out  properly  and  scientifically,  rapid  manipulation  is  not  only 
more  efficacious,  but  is  more  free  from  risk  than  the  slow  and 
tedious  process  of  stretching  the  opposing  tissues  little  by 
little. 

Strange  as  it  may  seem  at  first  sight,  there  is  scarcely  any- 
thing in  the  proceeding  itself  that  can  cause  inflammation. 
Tearing  across  bands  of  fibrous  tissue  is  no  more  likely  to  pro- 
duce it  than  breaking  a  bone  or  dividing  a  tendon.  There  is 
little  that  is  different  and  nothing  that  is  exceptional  in  the 
nature  of  the  injury.  A  certain  amount  of  blood  is  extra  va- 

1  The  following  instances  in  which  manipulation  was  either  at- 
tempted or  proposed  are  mentioned  by  the  author  of  one  of  the  most 
recent  and  complete  works  on  Diseases  of  the  Joints  (Howard  Marsh) 
as  having  occurred  under  his  own  observation :  — Malignant  tumor  of 
the  thigh ;  malignant  tumor  of  the  shoulder ;  disease  of  the  spine ; 
three  cases  of  scrofulous  disease  of  the  knee-joint ;  haemorrhoids ;  and 
a  case  in  which,  after  the  hip- joint  had  already  been  excised,  it  was 
gravely  declared  that  the  bone  was  out,  and  must  be  replaced.  The 
list  could  easily  be  extended. 


1 1 2  Sprains ;  their  Consequences  and  Treatment. 

sated ;  the  vessels  dilate ;  more  lymph  is  poured  out  to  repair 
the  damage;  but  unless  there  is  some  grave  constitutional 
affection  present  in  addition,  or  it  is  followed  up  by  serious 
maltreatment,  this  is  no  more  likely  to  excite  inflammation 
than  a  single  bruise  or  subcutaneous  laceration  in  any  other 
part  of  the  body.  The  capsule  of  a  joint  is  always  extensively 
torn  in  dislocations,  but  they  are  never  followed  by  inflamma- 
tion unless  some  similar  cause  is  present,  and  it  is  difficult  to 
understand  why  it  should  be  so  much  feared  when  the  injury 
is  so  much  less. 

Slow  and  Gradual. — Repeated  straining1,  on  the  other  hand, 
constantly  attempting-  to  stretch  the  contracted  tissues,  is 
one  of  the  surest  ways  of  exciting-  it.  It  does  not  matter  how 
carefully  it  is  managed.  Each  time  a  stiffened  joint  is  gently 
worked  the  fibrous  bands  that  check  its  movements  are 
stretched,  and  very  likely  slightly  torn;  each  time,  in  short, 
the  tissues  are  sprained  again,  so  that  they  become  more  and 
more  tender  and  swollen.  One  of  two  things  then  must  hap- 
pen. Either  the  interval  before  the  next  attempt  is  not  long 
enough  for  them  to  recover,  the  heat  and  swelling  never  have 
time  to  subside,  and  the  joint  becomes  inflamed,  though  it  does 
not  regain  its  freedom,  or  for  fear  of  such  an  untoward  occur- 
rence manipulation  is  abandoned  for  a  time,  thorough  rest  en- 
joined, and  all  the  improvement  lost;  the  bands  regain  their 
strength,  and  the  stiffness  becomes  worse  than  it  was  before. 
One  method  aims  at  restoring  perfect  freedom  at  once  with 
a  single  risk;  in  the  other  the  danger  is  incurred  again  and 
again,  each  occasion  being  worse  than  the  one  that  preceded 
it,  without  the  chance  of  recovery  being  nearly  so  good 

Accidental  Bone-setting. — I  must  not  be  understood  to 
advocate  indiscriminate  employment  of  forcible  movement  in 
all  cases  alike;  it  is  just  this  which  has  brought  it  into  such 
disrepute,  and  caused  such  an  amount  of  opposition;  only 
where  other  things  are  equal,  adhesions  in  connection  with 
sprained  joints  are  far  better  broken  across,  once  for  all,  than 
repeatedly  strained  and  stretched.  There  is  no  difficulty  in 
supplying  examples  in  proof  of  this.  One  I  have  mentioned 
already  while  describing  the  changes  that  occur  in  the  tissues 
round  a  joint  after  injury,  and  it  is  by  no  means  a  solitary,  or 
even  an  unusual,  case.  A  very  similar  one  was  narrated  to 
me  a  short  time  since  by  another  patient.  According  to  his 


Sprains;  tJieir  Consequences  and  Treatment.  113 

own  account,  he  had  fallen  clown,  with  his  arm  outstretched, 
some  time  before,  and  (as  was  very  probable)  had  dislocated 
his  shoulder.  It  was  reduced  by  a  surgeon,  but,  for  fear  of 
reproducing  the  dislocation,  the  arm  was  kept  bandaged  close 
to  the  side  for  nearly  six  weeks.  At  the  end  of  that  time  he 
could  scarcely  move  it,  and  was  almost  convinced  from  the 
stiffness  of  the  joint  that  the  dislocation  had  never  been  re- 
duced at  all.  It  got  better,  however,  by  slow  degrees,  until 
he  was  able  to  move  his  arm  in  all  directions,  except  upward 
and  outward;  the  least  attempt  at  this  was  stopped  at  once 
by  a  sharp  stab  of  pain  on  the  inner  and  under  side  of  the 
joint.  This  continued  until  one  day,  about  four  months  after 
the  original  accident,  falling  down  again  in  much  the  same 
way,  he  felt  a  sudden  snap,  which  hurt  him  intensely  for  the 
moment.  Probably  this  was  due  to  the  rupture  of  a  band,  or 
of  some  contracted  portion  of  the  capsular  tissue;  at  any  rate, 
he  found  to  his  astonishment  that  his  arm  was  from  that 
moment  practically  free.  Nothing  afterward  could  turn  him 
from  the  belief  that  the  same  kind  of  fall  had  both  dislocated 
and  reduced  his  shoulder  joint.  It  was  certainly  wonderful 
that  he  did  not  dislocate  it  a  second  time. 

In  the  ankle,  when  it  is  left  stiff  and  painful  after  a  sprain 
or  fracture,  manipulation  carried  out  in  this  way  is  always 
worth  trying.  The  particular  kind  of  case  in  which  it  is  likely 
to  be  successful  can  often  be  recognized  at  once.  The  skin 
over  it  is  red  and  shining,  as  if  it  were  stretched  too  tight; 
the  color  disappears  readily  when  it  is  pressed  upon,  but  is 
very  slow  in  returning;  firm  pressure  often  causes  it  to  pit, 
especially  where  there  is  a  large  amount  of  subcutaneous  tis- 
sue; at  the  same  time  it  feels  cold  to  the  touch.  There  is  no 
displacement  or  dislocation;  the  outline  of  the  bones  is  quite 
natural,  though  all  the  depressions  are  partly  filled  up,  and 
the  prominences  rounded  off;  and  the  tendons  can,  generally 
speaking,  be  traced  to  their  grooves.  The  position,  however, 
is  awkward,  so  that  when  standing  upright  the  sole  cannot 
rest  flat  upon  the  ground;  movement  is  limited,  and  exceed- 
ingly painful  at  certain  spots;  and  there  is  constant  aching, 
especially  at  night  or  after  any  exertion.  In  several  cases 
such  as  this,  by  putting  the  patient  under  an  anaesthetic  and 
working  the  joint  thoroughly,  I  have  succeeded  in  restoring 
perfect  freedom  of  movement,  sometimes  at  the  first  attempt. 


114  Sprains ;   their  Consequences  and  Treatment. 

It  is  essential  to  recollect  in  dealing  with  this  part  that  though 
the  original  injury  may  have  appeared  to  be  confined  to  the 
ankle,  the  other  joints  of  the  foot  rarely  escape  entirely;  and 
that  even  if  they  are  so  fortunate,  they  have  been  kept  con- 
tinuously at  rest  as  much  as  the  ankle,  and  have  undergone 
similar  changes.  For  want  of  this  precaution,  I  have  seen 
more  than  one  case  fail  at  the  first,  and  only  succeed  when  the 
manipulation  was  extended  to  the  others  too. 

Sprains  of  the  wrist,  again,  often  leave  the  fingers  stiff  and 
rigid  for  weeks,  long  after  all  heat  and  swelling  have  disap- 
peared. In  a  case  recently  under  my  care  the  patient  had 
fallen,  about  three  weeks  before,  down  a  flight  of  steps,  bend- 
ing his  right  wrist-joint  beneath  him.  According  to  his  own 
account,  he  lay  for  some  time  (how  long  he  scarcely  knew) 
unconscious;  and  on  coming  round  found  that  his  arm  was  in- 
tensely painful,  and  that  there  was  an  enormous  amount  of 
swelling  over  the  back  of  the  hand  and  wrist,  extending  some 
distance  along  the  forearm.  This  was  reduced  by  careful 
bandaging,  so  that  when  I  saw  him  it  had  almost  disappeared, 
though  there  was  evidence  in  the  staining  of  the  skin  by  the 
elbow  how  severe  the  injury  had  been.  The  hand  was  quite 
cool  and  painless  so  long  as  it  was  left  alone,  but  he  had  not 
the  least  power  over  his  fingers;  they  lay  nearly  straight,  not 
apparently  hurt,  slightly  swollen  it  is  true,  so  that  the  shape 
of  the  joints  was  too  rounded  and  uniform,  but  with  nothing 
else  about  them  to  show  that  they  had  been  injured.  With 
the  aid  of  the  other  hand  he  could  almost  bend  them  down 
into  the  palm,  though  it  gave  him  a  considerable  amount  of 
pain;  but  as  soon  as  they  were  released  they  sprang  back 
again  almost  mechanically.  He  was  directed  to  have  the  part 
thoroughly  kneaded  and  steamed  for  a  few  days;  and  at  the 
end  of  the  week  was  placed  under  an  anaesthetic,  and  every 
joint  in  the  fingers  and  wrist  systematically  worked  through  its 
full  range.  The  next  day  the  hand  felt  very  sore,  and  was  slight- 
ly more  swollen,  but  this  soon  disappeared  under  massage. 
Movement  was  slow,  and  executed  with  great  deliberation, 
but  the  range  was  much  wider,  and  he  was  encouraged  to  use 
it  freely.  Two  days  after  full  power  had  nearly  returned,  and 
he  was  able  to  resume  his  work. 

Where  Rapid  Manipulation  is  Suitable. — The  joints  in 
which  this  plan  of  treatment  is  most  successful  are  those  which 


Sprains  ;  their  Consequences  and  Treatment.  1 1 5 

are  cold,  but  not  much  wasted,  where  the  adhesions  are  still 
recent,  and  especially  where,  from  the  pain  and  tenderness  be- 
ing1 constant  at  one  spot,  there  is  some  probability  of  the  con- 
tracted tissues  being-  limited  in  extent.  Hinge  joints,  in  which 
the  movements  are,  comparatively  speaking,  simple,  and  take 
place  only  in  one  plane,  can  be  treated  much  more  easily  than 
ball  and  socket  ones,  or  those  in  which  the  variety  of  move- 
ments is  more  extensive. 

An  anaesthetic  should  always  be  given  unless  there  is  some 
special  reason  against  it.  Not  only  does  it  render  the  opera- 
tion painless,  but  by  insuring-  that  the  muscles  are  relaxed,  it 
enables  the  maximum  result  to  be  obtained  with  the  least 
degree  of  violence.  In  many  cases,  indeed,  it  is  necessary,  in 
order  to  make  the  diagnosis  exact;  so  long  as  the  muscles 
are  contracted,  it  is  often  impossible  to  give  an  opinion  either 
as  to  the  strength  or  the  extent  of  the  adhesions.  The  ob- 
struction itself  may  be  of  the  slightest  description,  and  the 
limb  so  rigid  as  apparently  to  have  lost  the  joint  altogether. 
No  ordinary  degree  of  force  may  produce  the  least  effect;  but 
as  soon  as  the  contraction  of  the  muscles  is  done  away  with, 
the  mere  weight  of  the  part  is  sufficient  to  separate  the  adher- 
ent surfaces,  and  restore  perfect  freedom. 

Preparation. — When  some  time  has  escaped  since  the  acci- 
dent, and  the  circulation  is  feeble,  or  when  the  skin  and  the 
subcutaneous  tissues  appear  thin  and  shrunken,  it  is  not  ad- 
visable to  attempt  this  without  a  certain  degree  of  prepara- 
tion. The  joint  should  be  well  steamed,  or  douched  with  water 
from  a  jet  of  moderate  diameter,  commencing  with  it  fairly 
warm,  and  finishing  up  with  cold;  or  it  should  be  thoroughly 
kneaded  every  day,  for  a  week  or  a  fortnight,  to  loosen  the 
skin  and  bring  back  the  circulation.  No  pains  should  be  spared 
to  insure  this.  Great  stress  is  laid  by  some  on  the  use  of  oil, 
which  is  to  be  well  rubbed  in;  and  certain  kinds  are  much 
more  highly  recommended  than  others;  but  in  all  probability 
the  beneficial  effect  is  entirely  due  to  the  friction.  A  small 
quantity  of  oily  matter  is  no  doubt  absorbed,  but  it  is  impos- 
sible to  imagine  that  its  action  under  these  conditions  is  me- 
chanical, as  this  would  imply. 

The  operation  itself  is  not  so  simple  as  might  be  imagined. 
It  is  true  that  occasionally  the  most  extraordinary  recoveries 
are  effected  by  falls  or  other  accidents ;  but  it  must  always 


n6  Sprains;  their  Consequences  and  Treatment. 

be  remembered  that  these  are  only  heard  of  when  they  are 
successful ;  and  that,  very  probably,  they  are  quite  the  excep- 
tion. In  the  majority  of  cases  failure  is  much  more  likely,  un- 
less a  definite  and  well-ordered  scheme  is  followed  out. 

Method. — The  chance  of  success  is  greatest  when  the  ob- 
struction can  be  accurately  localized.  No  pains  should  be 
spared  to  effect  this.  The  joint  must  be  thoroughly  examined 
in  every  position  it  can  be  made  to  assume;  any  spot  that  is 
tender  must  be  marked  beforehand;  the  movements  that 
cause  an  increase  in  the  pain  must  be  noted,  both  as  regards 
direction  and  extent,  as  well  as  the  least  irregularity  or  un- 
even ness  as  one  part  glides  over  another.  It  is  entirely  owing 
to  their  power  of  appreciating  minutiae  of  this  description  that 
some  persons  have  acquired  such  a  reputation  for  the  treat- 
ment of  these  cases. 

The  patient  must  be  placed. so  that  the  portion  of  the  limb 
between  the  affected  joint  and  the  trunk  can  be  fixed  securely 
by  an  assistant  while  the  lower  part  can  be  freely  moved  by 
the  operator.  In  the  case  of  the  larger  joints,  one  hand  should 
grasp  the  limb  immediately  below,  so  that  the  thumb  may 
press  firmly  on  any  spot  that  is  tender;  the  other  must  be 
sufficiently  far  off  to  secure  a  proper  amount  of  leverage.  All 
rapid  movements  should,  so  far  as  possible,  be  in  the  direction 
of  flexion,  combining  with  it  abduction,  adduction,  or  rotation, 
according  to  the  case,  so  that  the  tension  may  be  directed  to 
the  required  spot. 

To  carry  this  out  effectually  two  things  are  needed  beyond 
all  others.  The  one  is  a  sense  of  touch  so  delicate  that  it  can 
appreciate  the  least  resistance  or  irregularity  of  movement ; 
the  other  an  accurate  knowledge,  not  merely  of  the  ordinary 
anatomy  of  the  part,  but  of  the  different  degrees  of  tension 
that  fall  on  the  ligaments  in  every  position  of  the  limb. 

Each  joint  requires  a  different  kind  of  manipulation  accord- 
ing to  its  construction.  In  the  case  of  the  shoulder,  for  ex- 
ample, the  elbow  must  be  bent  so  that  the  forearm  may  be 
used  as  a  lever,  and  the  arm  rotated  first  to  one  side  then  to 
the  other,  bringing  it  across  the  chest  and  carrying  it  round 
behind  the  back  before  any  attempt  is  made  to  raise  it  from 
the  side.  Bringing  it  up  at  once  would  very  likely  dislocate 
the  joint.  For  the  knee  Hood  recommends  the  foot  of  the 
affected  limb  to  be  held  by  the  operator  between  his  thighs, 


Sprains;  their  Consequences  and  Treatment.  117 

so  that  when  flexion  is  accomplished  by  the  hand  it  may  serve 
as  a  lever  for  rotation.  This,  however,  can  be  effected  by  the 
hands  alone  if  the  muscles  have  been  relaxed  by  an  anaesthetic. 
The  smaller  hinge  joints  can  be  managed  even  more  easily, 
flexion  being-  combined  with  lateral  or  rotatory  movements  so 
far  as  the  shape  of  the  bone  will  allow. 

There  should  be  no  jerking.  The  movements  must  be  vig- 
orous and  forcible,  but  perfectly  smooth ;  and  they  must  be 
carried  out  thoroughly,  the  joint  being  moved  to  its  full  ex- 
tent in  all  directions  that  are  natural  to  it.  Each  kind  of 
action  should  be  combined  successively  with  the  rest,  one  by 
one,  so  that  the  tension  may  fall  in  turn  upon  all  the  different 
parts  of  the  capsule. 

Movements  which  are  especially  restricted  or  painful  of 
course  require  most  attention,  but  the  others,  though  they 
may  not  be  affected  to  the  same  extent,  are  not  to  be  neglected. 
It  sometimes  happens  if  these  are  dealt  with  first  that  a  con- 
siderable proportion  of  the  main  obstruction  is  cleared  away, 
as  it  were,  by  side  attacks,  so  that  when  its  turn  comes  it 
yields  more  readily  than  it  otherwise  would. 

Recent  slight  adhesions  give  way  at  once  without  a  sound, 
though  the  sensation  is  generally  conveyed  to  the  hand.  When 
they  are  older  the  noise  may  be  as  loud  and  clear  as  when  a 
bone  is  broken.  Probably  in  many  cases  this  is  due  not  so 
much  to  the  actual  tearing  of  adhesions  as  to  the  sudden  sep- 
aration of  two  synovial  surfaces  that  fit  accurately  into  each 
other.  The  noise  that  can  be  produced  in  this  way,  especially 
if  a  table  or  other  structure  is  made  use  of  as  a  sounding 
board,  is  well  known. 

The  after  treatment  of  these  cases  should  be  in  all  respects 
the  same  as  that  of  a  recent  sprain,  only  if  passive  motion  at 
an  early  date  is  advisable  to  prevent  the  occurrence  of  stiff- 
ness in  the  one,  it  is  absolutely  necessary  in  the  other.  The 
joint  must  be  worked  systematically  every  day  from  the  first. 
If  the  adhesions  have  been  thoroughly  broken  across,  and  if 
swelling  is  prevented  by  compression,  it  is  almost  painless.  In 
exceptional  cases  it  may  be  necessary  to  administer  an  anaes- 
thetic the  first  few  times. 

Manipulation  as  an  Exercise.— This,  however,  is  not  the 
only  use  for  forcible  manipulation.  Even  when  all  adhesions 
have  been  broken  down  and  the  action  of  the  joint  thoroughly 


n8  Sprains;  their  Consequences  and  Treatment. 

re-established,  voluntary  power  is  often  slow  in  returning1. 
The  joint  itself  may  move  with  perfect  freedom,  but  the  mus- 
cles, and  even  the  nerves,  seem  to  have  lost  their  power.  It 
is  so  long  since  they  have  done  any  work  that  they  have  be- 
come unable  to  do  any.  They  are  wasted  and  shrunken  in 
size;  the  circulation  in  them  is  defective;  possibly  their  struct- 
ure, even,  has  undergone  some  alteration.  Whatever  it  may 
be  there  is  no  question  that,  when  a  case  has  lasted  any  time, 
their  strength  and  vigor  become  seriously  impaired.  The 
joint  cannot  be  considered  cured  merely  because  the  mechan- 
ical obstacles  to  its  action  have  been  removed;  something 
more  than  this  is  required.  Recovery  is  not  complete  until  the 
natural  condition  is  restored,  and  the  joint  is  able  to  under- 
take active  work  again. 

Exercise,  of  course,  is  the  most  effectual  remedy  for  this. 
When  it  can  be  carried  out  the  cure  is  rapid  and  certain,  but 
in  many  cases  it  seems  impossible.  Sometimes  there  appears 
to  be  an  actual  inability  to  make  use  of  the  muscles,  as  if  the 
power  of  the  will  was  unable  to  reach  them.  Sometimes  the 
sense  of  insecurity  is  so  great  that  the  patient  cannot  be  per- 
suaded to  place  sufficient  trust  in  them.  Whatever  the  cause 
may  be,  forcible  manipulation  is  of  the  greatest  service  in 
these  cases,  especially  if  it  is  helped  by  massage  and  galvan- 
ism. The  way  in  which  it  is  used  is,  of  course,  very  different 
to  that  already  described,  and  the  object  is  different;  in  the  one 
its  purpose  is  to  tear  across  adhesions,  in  the  other  to  rouse 
latent  muscular  activity,  but  if  used  systematically,  success, 
though,  perhaps,  not  quite  so  conspicuous,  is  equally  sure. 
Elaborate  accounts  have  been  written  from  time  to  time  of 
what  has  been  called  the  movement  cure,  and  many  varieties 
of  manipulation  have  been  described  in  connection  with  it,  but, 
so  far,  at  least,  as  the  treatment  of  sprains  is  concerned,  it 
does  not  seem  clear  that  they  possess  any  great  advantage 
one  over  the  other.  The  principle  in  them  all  alike  is  to  exer- 
cise the  muscles  according  to  their  strength,  to  stretch  them 
out,  and  manipulate  them  without  fatigue.  In  most  cases  the 
greatest  amount  of  benefit  appears  to  be  obtained  by  making 
use  of  the  different  plans  successively,  beginning  with  that 
which  calls  for  the  least  effort  on  the  part  of  the  patient. 

Simple  extension,  gradually  straightening  out  the  muscles, 
one  after  the  other,  with  some  degree  of  force,  until  a  distinct 


Sprains;   their  Consequences  and  Treatment.  119 

sensation  of  resistance  is  experienced,  is  especially  useful  in 
the  earlier  stages,  immediately  after  the  adhesions  have  been 
broken  down.  Sometimes  the  muscles  are  irritable,  and  in- 
clined to  painful  spasmodic  contraction ;  or  hard  knots  form  in 
their  substance,  possibly  due  to  rupture  of  a  few  of  the  fibres; 
or  a  certain  degree  of  soreness  and  tenderness  of  skin  makes 
itself  felt  over  them.  Whatever  may  underlie  them,  these 
conditions  are  often  relieved  by  slowly  but  firmly  extending-, 
one  after  the  other,  the  various  groups  of  muscles  that  lie 
round  the  joint,  and  applying  firm  and  even  pressure. 

What  are  known  as  resistive  movements  are  of  much  wider 
application.  In  these  the  patient  either  carries  out  a  definite 
course  of  action  against  the  resistance  of  the  operator,  who 
is  able  to  select  any  particular  group  of  muscles,  and  regulate 
exactly  the  amount  of  work,  or  the  latter  makes  use  of  his 
strength  to  oppose  some  voluntary  action  on  the  part  of  the 
patient,  compelling  him  to  give  way.  The  former  of  these 
methods  is  by  far  the  most  useful  of  the  two.  The  secret  is 
to  keep  the  opposing  force  well  within  the  limits  of  the  patient's 
strength,  making  use  alternately  of  flexion  or  extension,  or  of 
rotation  inward  or  outward,  as  the  case  may  be.  Exercise 
of  this  description  certainly  possesses  wonderful  influence  on 
the  nutrition  and  activity  of  the  tissues,  not  the  muscles  only; 
and  with  a  reasonable  amount  of  care  it  may  be  kept  up  for 
a  considerable  time  each  day  without  overfatigue.  The  other 
plan  tires  out  the  muscles  at  once,  and  is  too  exhausting  to 
deserve  strong  recommendation. 

In  some  cases  it  is  possible  to  substitute  for  the  hand  of  the 
operator  mechanical  contrivances,  arrangements  of  wheels  and 
levers  adjusted  to  resist  any  individual  movement  that  may 
be  wished,  and  capable  of  being  graduated  exactly  by  the 
patient  to  suit  his  own  strength.  The  action,  however,  is  not 
quite  the  same.  The  resistance  of  a  spring  or  an  elastic  band 
cannot  be  graduated  like  that  of  human  muscles,  guided  by 
an  experience  of  what  is  required;  and  unless  very  carefully 
superintended  the  progress  of  cases  treated  in  this  fashion  is 
apt  to  be  very  uneven  and  irregular. 


CHAPTER  X. 

MASSAGE. 

MASSAGE,  again,  which  is  a  most  valuable  remedy  in  the 
treatment  of  sprained  joints,  has  a  history  as  strange  as  that 
of  forcible  manipulation.  It  has  never  been  altogether  for- 
gotten; some  people  have  always  practiced  it,  more  or  less 
carefully,  and  with  a  varying  degree  of  knowledge  and  skill; 
but  at  certain  times,  and  in  certain  countries,  it  seems  to  have 
acquired  an  extraordinary  reputation,  and  then,  again,  almost 
capriciously  to  have  been  as  strongly  condemned.  Possibly 
fashion  may  account  for  it  in  certain  measure,  for  this  exerts 
an  influence  in  the  use  of  remedies  just  as  it  does  over  every- 
thing else;  but  something,  at  least,  must  be  attributed  to  the 
indiscriminate  and  unscientific  manner  of  its  application  by 
unskilled  persons  in  all  cases  alike,  whether  they  could  or 
could  not  be  benefited  by  it.  Like  many  other  things  it  has 
been  destroyed  by  its  own  popularity. 

It  is»  certainly  not  a  novelty;  in  most  countries  there  has 
been  handed  down  by  tradition  from  unknown  ages  a  custom 
of  treating  injuries  of  joints  and  muscles  by  friction  or  manip- 
ulation, and  in  some  places  this  has  been  considered  a  special 
prerogative  of  certain  families  or  individuals,  who,  by  dint  of 
long  practice  and  a  certain  delicacy  of  touch  (perhaps  inher- 
ited), have  attained  no  inconsiderable  degree  of  skill.  The 
modern  plan  is  simply  the  scientific  outcome  of  this ;  the  work- 
ing has  been  studied  more  accurately ;  its  action  on  the  tissues 
better  considered ;  and  certain  rules  laid  down  for  guidance  in 
the  selection  of  cases. 

At  one  time,  for  example,  Beveridge's  rubbers  were  well 
known  in  Edinburgh,  and  the  success  that  attended  their  treat- 
ment (which  was  carried  out  very  thoroughly  and  method- 
ically) had  a  marked  influence  on  the  practice  of  the  Continent. 
Then  the  process  was  almost  forgotten,  or,  at  any  rate,  was 


Sprains ;  their  Consequences  and  Treatment.  121 

rarely  employed,  except  in  country  districts,  where  rubbing1  is 
often  used,  in  a  rough  sort  of  way,  without  skill  of  any  kind 
other  than  that  derived  from  custom.  Lately,  again,  owing 
in  great  measure  to  the  exertions  of  Dacre  Fox,  in  England, 
and  Graham,  Norstrom,  Metzger,  and  others,  abroad,  it  has 
been  placed  on  a  scientific  basis,  and  received  once  more  into 
favor.  Even  at  the  present  day,  however,  there  is  too  great 
a  tendency  to  consider  it  a  quack  remedy,  and  to  hand  it  over 
to  persons  whose  chief  recommendation  is  that  they  act  as 
untiring  rubbing  machines,  without  following  any  definite  rules 
or  guidance. 

It  is  often  said  against  it  that  those  who  take  it  up  abandon 
it  again  as  soon  as  they  have  had  sufficient  experience  of  its 
results;  they  find,  so  it  is  alleged,  that  not  only  does  it  require 
a  large  amount  of  patience  on  the  part  of  the  sufferer,  as  well 
as  the  operator,  but  that  it  is  only  beneficial  to  those  who 
would  recover  as  soon  without  it,  and  that  in  some  cases  it  is 
actually  injurious.  As  a  rule,  and  so  far  as  sprains  at  any 
rate  are  concerned,  this  arises  from  the  inability  to  distinguish 
massage  from  mere  unskilled  rubbing.  In  reality  there  is 
nearly  as  great  a  difference  between  them  as  there  is  between 
painting  the  wall  of  a  house  and  the  work  of  a  skilled  artist. 
The  one  requires  a  certain  amount  of  muscular  strength  and 
manual  dexterity,  the  other  only  comes  to  those  who  are  by 
nature  fitted  for  it,  as  a  result  of  teaching  and  experience.  It 
may  or  may  not  be  true  that  it  requires  two  years,  as  Dr. 
Murrell  states,  to  learn  the  process ;  that  depends  on  the  per- 
son and  on  the  previous  training;  certainly  many  do  not 
acquire  the  art  even  in  that  time. 

As  a  general  application  massage  is  very  widely  used. 
There  are  many  descriptions  copied  from  travelers'  works  of 
its  employment  in  one  form  or  another  among  most  of  the 
races  of  mankind.  It  was  largely  practiced  by  the  ancients; 
the  Turks  and  Africans  at  the  present  day  make  use  of  it; 
even  among  the  Siberians  and  Laplanders  it  may  be  found  in 
a  form  modified  by  the  exigencies  of  climate ;  while  the  "  lomi- 
lomi"  of  the  Sandwich  Islanders  is  spoken  of  in  terms  of  en- 
thusiasm by  nearly  every  one  who  has  written  of  them  for  its 
power  of  relieving  the  stiffness  and  soreness  of  excessive  ex- 
ertion, and  procuring  rest  and  sleep.  The  effect  is  described 
as  most  luxurious;  the  process  is  neither  kneading,  squeezing, 


122  Sprains ;  their  Consequences  and  Treatment. 

nor  rubbing,  but  now  like  one,  now  like  the  other,  each  muscle 
is  manipulated  in  its  turn,  beginning  with  the  head  and  work- 
ing down  slowly  over  the  whole  body,  until  in  half-an-hour 
the  weariness  has  quite  disappeared  and  given  place  to  a  most 
refreshing  sense  of  ease  and  comfort. 

Like  many  other  words  that  have  crept  into  science  from 
popular  usage,  massage  has  scarcely  yet  acquired  a  precise  or 
definite  meaning.  It  has  been  used  for  every  kind  of  manipu- 
lation, whether  applied  to  joints  alone  or  to  the  whole  surface 
of  the  body,  with  the  hands  only,  or  with  the  assistance  of  in- 
struments. All  varieties  of  friction,  pressure,  kneading,  per- 
cussion, and  even  passive  motion,  have  been  included  in  it  at 
one  time  or  another;  and  the  description  of  the  manner  in 
which  it  is  carried  out,  and  the  rules  by  which  suitable  cases 
are  selected,  are  proportionately  vague  and  uncertain. 

For  all  practical  purposes,  so  far,  at  least,  as  concerns  the 
treatment  of  injured  joints  and  muscles,  the  various  processes 
that  have  been  enumerated  may  be  grouped  under  the  three 
heads  of  friction,  percussion,  and  kneading.  Passive  motion 
differs  to  such  an  extent  in  its  object  and  method  of  applica- 
tion that  it  seems  unwise  to  include  it. 

Friction. — Of  these  friction  is  by  far  the  most  simple,  and 
the  easiest  and  least  fatiguing  to  carry  out;  but  its  power  is 
very  limited,  and  it  has  scarcely  any  direct  influence,  except 
on  the  most  superficial  structures.  It  consists  merely  in  a 
succession  of  strokings  with  the  hand  (using  as  much  of  the 
surface  as  possible,  and  fitting  it  into  all  the  inequalities)  from 
the  extremities  toward  the  trunk,  commencing  lightly  at  first, 
and  gradually  increasing  in  strength  as  the  part  becomes  ac- 
customed to  it.  The  knuckles  even  may  be  used  where  the 
tissues  are  very  deep-seated,  or  unusually  firm.  The  skin  soon 
becomes  red  and  warm ;  more  blood  flows  through  it,  the  tem- 
perature rises,  and,  after  a  few  days'  treatment,  a  distinct 
change  may  be  noticed  in  the  nutrition  of  the  part.  Instead 
of  being  hard  and  unyielding,  tied  down,  as  it  were,  to  the 
subjacent  tissues,  the  skin  becomes  soft  and  supple,  the  natural 
appearance  returns,  the  folds  become  visible  again,  and  the 
superficial  tissues  begin  to  regain  their  firmness  and  elasticity. 

Besides  this,  however,  friction  exerts  considerable  influence 
on  the  nerves  distributed  to  the  skin,  and  indirectly  through 
them  on  internal  organs,  especially  on  other  parts  of  the 


Sprains ;  their  Consequences  and  Treatment.  123 

nervous  system.  The  medium  through  which  this  takes  place 
is  not  accurately  known.  It  is  possibly  the  result  of  the  in- 
creased activity  of  the  circulation,  but  more  probably  it  is  due 
to  the  peculiar  sympathy  existing-  between  different  parts  of 
the  nervous  system,  by  virtue  of  which  one  cannot  be  stimu- 
lated or  excited  without  influencing1  the  rest.  However  this 
may  be,  of  the  fact  itself  there  can  be  no  doubt;  friction,  es- 
pecially along  the  back,  is  often  of  the  greatest  service  in  re- 
lieving irritability  or  sleeplessness. 

Combined  with  baths,  and  applied  generally  over  the  sur- 
face of  the  body,  it  is  of  excellent  service  when  the  limbs  are 
aching  and  stiff  from  over-exertion  or  exposure  to  cold.  It 
allays  the  sensitiveness  of  the  skin,  leaves  behind  it  a  feeling 
of  well-being  and  comfort,  and  does  away  with  the  sensation 
of  fatigue.  In  sprains,  howrever,  and  injuries  of  like  char- 
acter, its  application  is  more  limited.  In  recent  cases,  where 
there  is  no  extensive  laceration  of  ligaments,  and  where  it  is 
thought  advisable  to  begin  massage  without  delay,  it  may  be 
used  as  a  preliminary  to  allay  the  sensibility  of  the  skin,  and 
accustom  the  patient  to  firmer  kneading.  In  old  chronic 
cases,  too,  where  the  joint  has.  not  been  moved  for  some  length 
of  time,  it  is  of  undoubted  use  in  restoring  the  natural  tone  to 
the  skin  before  more  active  measures  are  undertaken.  In 
other  circumstances  it  is  rarely  employed  for  injuries  of  joints, 
though  it  is  highly  recommended  as  part  of  general  massage 
for  other  disorders. 

Percussion, — Percussion,  too,  whether  carried  out  by  means 
of  an  instrument  or  writh  the  hand,  is  of  very  limited  use.  Un- 
less applied  with  such  force  as  to  cause  actual  bruising,  it  has 
no  direct  influence  on  any  structure  deeper  than  the  skin  and 
the  subcutaneous  stratum  of  muscles.  On  the  former  it  pro- 
duces the  same  general  result  as  friction,  though  without  its 
soothing  influence;  on  the  latter  it  acts  as  a  local  stimulus, 
causing  each  time  a  single  contraction  of  the  fibres  beneath, 
varying  in  extent  and  vigor  according  to  the  condition  of  the 
muscles.  To  produce  the  full  effect,  the  movement  must  be 
rapid  and  short,  the  pressure  being  raised  at  once.  The 
weight  of  the  blow  must  be  regulated  by  the  depth  of  the 
structure.  Great  stress  is  laid  by  some  on  the  number  per 
minute,  when  percussion  is  used  for  the  relief  of  pain  or  neu- 
ralgia; but,  so  far  as  the  muscles  are  concerned,  this  does  not 


1 24  Sprains ;   their  Consequences  and  Treatment. 

seem  material,  though  it  is  as  well  the  strokes  should  not  be 
too  rapid. 

The  effect  is  most  marked  when  the  muscles  are  in  a  state 
of  tension,  though  the  actual  shortening-  produced  in  these 
circumstances  may  be  less  apparent.  When,  for  example,  the 
lumbar  region  is  being  percussed,  the  patient  should  stoop  for- 
ward, so  that  the  muscular  slips  lying  along  the  side  of  the 
spinal  column  may  be  placed  upon  the  stretch,  and  receive  the 
full  effect  of  the  vibration.  Otherwise  a  considerable  amount 
of  the  benefit  is  lost  before  the  muscular  substance  is  affected 
at  all. 

Massage. — Massage,  in  the  strict  sense  of  the  term,  is  a 
great  deal  more  efficacious,  especially  with  older  sprains.  Its 
action  is  not  limited  to  the  skin  and  superficial  structures. 
These  undergo  immense  changes,  it  is  true ;  they  become  softer 
and  finer  while  under  manipulation;  their  strength  and  elas- 
ticity increase,  the  extreme  tenderness  diminishes,  and  the 
natural  appearance  and  texture  return.  The  surface  loses  its 
dry  harsh  character  and  becomes  warm  and  moist  again;  the 
livid  bluish  color  gives  way  to  a  brighter  hue,  and  the  deeper 
layers  of  fibrous  tissue  yield  and  stretch,  so  that  the  hide-bound 
shrunken  condition  that  is  often  present  after  long  disuse 
gradually  passes  off.  But  the  good  effect  is  not  by  any  means 
limited  to,  or  even  most  conspicuously  shown  by  this.  When 
properly  carried  out  massage  exerts  a  simultaneous  influence 
on  muscles,  nerves,  and  vessels,  in  fact  on  all  the  tissues  within 
its  reach. 

The  circulation  is  the  first  thing  to  feel  its  power.  It  has 
already  been  explained  how,  after  prolonged  rest,  the  blood,  as 
it  were,  lies  almost  stagnant  in  the  tissues,  slowly  circulating 
through  them,  and  neither  giving  them  sufficient  for  their 
nutrition,  nor  removing  from  them  the  waste  products  of  their 
action.  This  is  changed  at  once.  The  life  of  the  part  is  quick- 
ened. The  veins  and  absorbents  are  emptied  first,  and  the 
fluid  they  contain  driven  on  to  the  heart,  which  fills  more 
rapidly,  and  contracts  more  vigorously  and  firmly.  Then  the 
pressure  falls  on  the  smaller  vessels,  and  the  tiny  irregular 
spaces,  full  of  lymph,  which  extend  in  all  directions  through 
the  tissues.  These,  in  their  turn,  are  compressed  and  me- 
chanically emptied,  their  contents  being  driven  on  into  the 
empty  vessels,  from  which  any  backward  flow  is  prevented  by 


Sprains ;  their  Consequences  and  Treatment.  125 

the  valves.  The  circulation  becomes  more  rapid;  nutrition  is 
carried  on  with  greater  energy,  and  the  actual  amount  of 
blood  in  the  tissues  at  any  one  time  so  much  increased  that 
they  become  full  and  soft  to  the  touch  and  regain  the  even  and 
rounded  contour  of  active  health. 

Next  to  the  skin  the  muscles  seem  to  experience  the  great- 
est amount  of  benefit.  Even  after  a  single  application  they 
are  capable  of  doing-  a  great  deal  more  work  with  much  less 
fatigue.  It  has  often  been  shown  that  a  muscle,  exhausted  by 
lifting-  a  heavy  weig-ht  many  times  in  a  minute,  scarcely  re- 
gains any  of  its  power  if  it  is  merely  allowed  to  rest  a  quarter 
of  an  hour.  It  remains  stiff  and  weak,  and  liable  to  irreg-ular 
and  spasmodic  contractions.  If,  on  the  other  hand,  it  is  treated 
by  massag-e  for  the  same  length  of  time,  its  strength  returns, 
so  that  it  is  able  to  do  as  much  again  with  even  less  fatig-ue 
than  it  felt  before. 

At  the  same  time  the  sensitiveness  to  electric  stimuli  is  in- 
creased. Murrell  has  shown  that  a  current,  too  weak  to  cause 
any  response  when  applied  to  the  motor  point  of  one  of  the 
muscles  of  the  arm,  is  able  to  produce  vigorous  contraction 
after  a  few  minutes'  massage.  The  excitability  of  muscles, 
and  the  amount  of  energy  they  are  capable  of  putting  out,  are 
regulated — other  things  being-  equal — by  the  way  in  which 
they  are  supplied  with  food,  and  the  rapidity  with  which  the 
waste  products  are  removed.  This,  in  its  turn,  is  dependent 
on  the  circulation.  Each  muscle  and  each  bundle  of  muscular 
fibres  is  surrounded  by  a  sheath  of  fascia,  to  all  intents  and 
purposes  quite  inelastic;  under  this  is  collected  the  fluid  plasma 
which  is  the  immediate  source  of  the  nutrition  of  the  tissues. 
So  long-  as  the  muscle  is  at  rest  this  remains  unchanged;  when 
it  contracts,  so  that  the  shape  and  consistence  are  altered,  or 
when  the  muscle  itself  is  thoroughly  and  systematically 
kneaded,  the  fluid  is  driven  onward  into  the  lymphatics  and 
at  once  renewed  from  behind.  It  is  for  this  reason  that  mas- 
sage, so  far  from  causing-  fatigue,  is  of  such  service  in  reliev- 
ing it. 

The  good  effect  does  not  pass  off  at  once.  If  the  treatment 
is  continued  and  a  proper  supply  of  food  maintained  there  is  a 
lasting  increase  in  the  size  and  condition  of  the  muscles.  In- 
stead of  being  soft  and  flaccid  or  stiff  and  unyielding,  with 
hard  and  tender  nodules  in  their  substance,  so  that  ihey  rather 


126  Sprains;   their   Consequences  and  Treatment. 

impede  movement  than  otherwise,  they  become  firm  and  elastic 
to  the  touch,  ready  to  respond  at  once  to  any  stimulus,  and 
able,  when  called  upon,  to  put  out  a  much  greater  amount  of 
energy. 

It  is  hardly  fair,  however,  to  attribute  the  whole  of  this  im- 
provement to  the  condition  of  the  muscles  only.  Massage  ex- 
erts a  similar  influence  on  the  nervous  system,  and  though  the 
immediate  results  may  not  be  so  striking-  in  their  character, 
the  actual  chang-es  are  none  the  less  important.  During  the 
process  itself,  and  often  for  hours  after,  the  patient  experiences 
a  sense  of  refreshing-  ease  and  comfort.  Lassitude  and  pain 
disappear;  the  capacity  for  work  returns,  and  mind  and  body 
alike  regain  their  vigor.  Probably  this  results  in  no  small 
measure  from  the  improvement  in  the  circulation,  as  the  effect 
at  first  is  quite  local;  but  from  the  way  in  which  g-eneral 
strength  and  voluntary  power  are  restored,  in  what  are  known 
as  neurasthenic  cases,  massag-e  must  exert  a  very  considerable 
influence  upon  the  whole  of  the  nervous  system. 

In  Recent  Injuries. — The  best  proof,  however,  of  the  power 
it  possesses  over  absorption  and  circulation  is  shown  by  the 
ease  with  which  the  swelling-  and  tension  can  be  made  to  dis- 
appear from  sprained  joints.  It  is  true  that  in  recent  cases 
the  greatest  care  is  required,  and  that  nothing-  is  so  likely  to 
increase  the  mischief  as  rough  handling  of  the  part;  but  when 
it  is  carried  out  quietly  and  gently,  by  one  who  has  had  some 
experience,  it  is  very  difficult  to  find  anything  that  acts  in  so 
perfect  a  manner.  The  whole  limb,  perhaps,  is  swollen;  the 
joint  distended  with  blood;  the  skin  shining  and  tense,  much 
too  hot  to  the  touch,  and  exquisitely  tender ;  but  all  this  van- 
ishes almost  like  magic.  The  tension  disappears  as  the  fluid  is 
carried  off;  the  pain  is  relieved,  the  temperature  falls,  the 
natural  outline  begins  to  be  apparent  once  more,  extravasatecl 
blood  is  broken  up,  the  debris  dispersed,  and  adhesions  be- 
tween the  torn  and  bruised  surfaces  effectually  prevented. 
Sometimes  even  tendons,  which  have  been  turned  almost  out 
of  their  grooves  by  the  accumulation  of  fluid  in  their  sheaths, 
can  in  this  way  be  restored  to  their  position  without  further 
assistance. 

Such  results  as  these  cannot,  of  course,  be  obtained  in  every 
case  of  recent  sprain,  and  even  when  the  treatment  is  success- 
ful in  relieving-  the  pain  and  getting  rid  of  the  swelling,  it 


Sprains ;   their  Consequences  and  Treatment.  127 

must  always  be  remembered  that  time  is  needed  for  the  repair 
of  structures  that  have  been  torn.  I  am  convinced,  however, 
that,  especially  when  the  stress  of  the  injury  has  fallen  on  the 
muscles,  and  when  the  laceration  is  not  too  great,  this  plan 
may  be  adopted,  not  only  with  the  greatest  safety,  but  with 
an  infinitely  better  prospect  of  speedy  recovery  than  under  the 
old  established  method  of  bandaging  and  rest.  Graham,  in 
particular,  lays  stress  on  the  fact  that  the  sooner  the  treat- 
ment is  commenced  after  the  injury,  the  shorter  its  duration  is 
likely  to  be. 

In  Older  Cases. — In  older  cases,  where  the  effusion  is  denser 
and  firmer,  and  where,  owing  to  the  long-continued  distention, 
the  tissues  have  lost  their  tone,  and  become  sodden  and  cedem- 
atous,  massage  can  be  used  with  much  greater  freedom.  The 
solid  part  of  the  effusion  is  broken  up  and  disintegrated  by  the 
pressure,  so  that  it  is  driven  into  the  absorbents  and  carried 
away  by  the  increased  force  of  the  stream;  the  chronic  conges- 
tion is  dispersed,  the  blood  circulates  more  freely,  the  tone  of 
the  part  returns,  and  the  lifeless,  helpless  look  disappears  day 
by  day.  The  improvement  is  often  surprising  in  its  rapidity. 
A  joint  that  has  remained  for  weeks  cold  and  inactive,  the 
seat  of  a  constant  wearing  pain,  and  quite  incapable  of  per- 
forming its  proper  movements,  in  a  very  few  sittings  begins  to 
recover  its  flexibility,  loses  the  pain,  and  allows  itself  to  be 
handled,  and  passive  movements  to  be  carried  out  with  ease 
and  readiness. 

Active  movement,  in  general,  takes  some  time  longer,  for 
the  muscles  grow  so  stiff  and  rigid  from  prolonged  disuse  that 
they  require  as  much  education  as  the  joint  itself.  The  case 
that  furnishes  the  most  striking  cure  is  a  sprained  joint  that 
has  been  treated  by  bandaging  in  the  conventional  way,  where 
the  oedema  still  persists,  and  where  there  are  no  adhesions 
round  other  than  those  caused  by  the  rigidity  of  the  capsule 
and  the  swelling  of  the  soft  tissues.  Even  if  weeks  have  passed, 
the  effect  may  be  seen  after  the  second  or  third  sitting.  Only 
where,  owing  to  the  great  length  of  time,  the  effusion  has  be- 
come thoroughly  organized,  and  where  the  structures  round 
are  shrunken  and  matted  together  by  dense,  unyielding  fibrous 
tissue,  it  is  of  little  avail  until  the  joint  is  set  free,  and  full 
range  of  action  restored  by  vigorous  passive  movement. 

Method. — The  method  of   application  is  not  easy  to   de- 


128  Sprains ;   their  Consequences  and  Treatment. 

scribe,  and  it  can  only  be  learned  through  practice,  even  by 
those  who  already  possess  a  fair  knowledge  of  anatomy.  This 
is  indispensable;  without  it,  massage  must  degenerate  into 
mere  rubbing.  Each  group  of  muscles  must  be  known,  where 
it  ends  and  begins,  how  thick  it  is,  and  how  the  tendons  lie, 
where  the  intermuscular  septa  of  connective  tissue  come,  and 
where  the  vessels  and  nerves  that  supply  the  part  are  situated. 
All  the  natural  movements  and  the  different  arrangement  of 
the  structures  in  various  positions  of  the  limb  must  be  per- 
fectly familiar.  The  synovial  cavity  of  the  joints  and  the  ten- 
don sheaths  must,  as  it  were,  be  mapped  out  underneath  the 
skin.  In  short,  there  must  be  a  thorough  practical  knowledge, 
not  only  of  the  anatomy  of  the  part  at  rest,  but  of  the  direc- 
tion and  mutual  relations  assumed  by  the  different  structures 
when  at  work. 

Supposing  the  case  of  a  sprained  ankle  of  moderate  severity 
in  a  healthy  person,  a  few  hours  after  the  accident  the  liga- 
ments are  strained,  perhaps  even  slightly  torn;  the  synovial 
cavity  is  distended  with  fluid,  the  tissues  round  are  swollen  out 
with  extravasated  blood,  the  skin  is  hot  and  discolored,  the 
normal  shape  of  the  joint  is  lost,  and  all  the  hollows  between 
the  bones  are  filled  up.  The  patient  must  be  seated  comfort- 
ably, so  that  the  muscles  are,  as  far  as  possible,  relaxed ;  the 
knee  must  be  bent,  and  the  foot  and  ankle  given  over  alto- 
gether to  the  manipulator.  The  foot  is  to  be  held  gently  but 
firmly,  so  that  the  patient  may  make  no  incautious  start,  and 
the  whole  proceeding  from  first  to  last  should  be  entirely  de- 
void of  pain.  The  operator  should  have  plenty  of  room,  so 
that  he  is  not  cramped ;  perhaps  as  convenient  a  position  as 
any  is  kneeling  on  one  leg,  or  sitting  on  a  low  seat  in  front  of 
the  patient,  with  the  heel  of  the  injured  limb  resting  on  the 
front  of  his  knee.  The  movement  at  first  must  be  exceedingly 
light,  and  so  directed  as  to  diminish  as  much  as  possible  the 
sensitiveness  of  the  skin,  commencing  with  the  part  above 
(nearer  the  trunk)  the  injured  joint,  and  working  gradually 
downward.  The  thumb,  or  the  tips  of  the  fingers,  or  the  palm 
of  the  hand,  should  be  used  according  to  the  shape  of  the  sur- 
face, taking  care  always  to  employ  as  much  as  possible. 

The  direction  of  the  movement  must  always  be  toward 
the  trunk,  from  the  insertion  to  the  origin  of  the  muscles,  in 
the  direction  of  the  returning  current  of  the  circulation,  com- 


Sprains ;   their  Consequences  and  Treatment.  129 

mencing  over  a  part  where  the  swelling1  has  not  yet  shown 
itself,  and  gradually  working-  on  to  the  rest.  The  most  tender 
spots  must  always  be  left  till  last.  If,  for  example,  the  foot 
has  been  twisted  outward,  there  is  nearly  always  great  sen- 
sitiveness over  the  tip  of  the  internal  malleolus,  and  a  consid- 
erable amount  of  swelling-  along-  the  course  of  the  tendons 
behind,  extending-  a  variable  distance  up  the  leg,  and  into  the 
hollow  in  front  of  the  tendo-Achillis.  This  must  be  left  until 
friction  has  been  applied  over  the  whole  of  the  rest  of  the  foot 
and  leg-;  if  this  is  carried  out  thoroughly  not  only  does  a  great 
deal  of  the  swelling  disappear  of  itself  from  the  injured  part, 
but  owing  to  the  condition  of  the  circulation  through  that 
which  has  been  already  manipulated,  the  remainder  is  ab- 
sorbed much  more  readily  than  it  otherwise  would  be. 

Gradually,  if  the  treatment  is  persevered  in,  the  tendency 
to  start  on  the  part  of  the  patient,  and  even  the  involuntary 
shrinking,  disappear;  the  foot  is  given  up  to  the  operator  with 
greater  confidence,  and  the  superficial  general  swelling  begins 
to  diminish.  More  attention  may  then  be  paid  to  the  spaces  in 
which  the  extra vasated  blood  has  collected  to  the  cavity  of  the 
joint  and  the  tendon  sheaths.  The  tips  of  the  fingers,  or  the 
thumb,  may  be  made  to  trace  out  the  irregular  intervals  be- 
tween the  bony  prominences  moving  round  and  round  in  small 
circles  on  the  skin.  The  two  hands  should  be  used  close  to- 
gether, so  that  the  paths  the  fingers  traverse  intersect  each 
other,  and  the  manipulated  surfaces  overlap.  Gradually,  as 
the  effusion  subsides,  the  circles  increase  in  size,  the  pressure 
becomes  firmer,  and  the  deeper-lying  structures  are  treated  in 
their  turn.  The  individual  muscles  and  tendons  are  grasped 
and  squeezed  in  the  direction  of  their  fibres,  the  fingers  being  al- 
ways carried  onward  toward  the  trunk  in  the  interspaces  be- 
tween them ;  and  the  soft  tissues  are  firmly  pressed,  and,  as  it 
were,  rolled  along  by  one  hand  after  the  other,  until  all  the 
excess  of  fluid  has  returned  once  more  to  the  blood  stream,  and 
slight  passive  movements  of  such  a  nature  as  not  to  exert  any 
traction  on  the  injured  ligaments  are  allowed  without  resist- 
ance. 

This  is  to  be  taken  as  the  sign  of  success  in  the  treatment 
of  recent  cases.  How  long  before  it  is  reached  differs  natu- 
rally in  each  individual,  and  no  rule  can  be  laid  down.  Some- 
times in  slighter  injuries  a  single  short  sitting  suffices;  at 


13°  Sprains ;  their  Consequences  and  Treatment. 

others  the  process  must  be  repeated  for  several  days.  The 
time  that  has  elapsed  since  the  accident,  the  condition  of  the 
joint,  the  degree  of  swelling-,  and  the  severity  of  the  pain,  all 
possess  some  degree  of  influence.  As  a  general  rule,  if  the 
injury  is  recent,  there  is  more  tenderness  about  the  part,  but 
the  swelling*  disappears  sooner;  in  older  cases  firmer  pressure 
may  be  used  from  the  first,  as  the  skin  is  less  sensitive ;  but 
the  time  before  the  swelling  is  absorbed,  and  movement  be- 
comes free  and  painless,  as  a  rule  is  much  longer. 

At  the  close  of  the  sitting  the  joint  and  the  limb  must  be 
bandaged  with  pads  of  cotton  wool,  so  arranged  as  to  fill  in 
all  the  natural  depressions  of  the  part.  If  they  are  held  in 
place  with  a  flannel,  or  better  a  Domett  bandage,  the  joint 
may  be  moved  a  little,  though  the  pressure  is  sufficient  to  pre- 
vent the  return  of  any  great  degree  of  swelling  and  oedema. 
But,  however  carefully  the  bandage  is  applied,  it  nearly  always 
happens  that  the  next  day  some  of  the  fullness  and  tenderness 
of  the  part  returns,  so  that  another  sitting  is  desirable.  If 
the  case  is  g-oing  to  terminate  favorably,  each  application  is 
shorter  and  less  painful  than  the  last,  and  each  time  the  range 
of  passive  movement  is  increased. 

It  must  clearly  be  borne  in  mind  that,  though  this  method 
of  treatment  causes  the  swelling  to  disappear  more  rapidly 
than  any  other,  and  allows  the  return  of  slight  degrees  of 
movement  without  pain  almost  from  the  first,  a  ligament  that 
has  been  torn  across  requires  nearly  as  long  for  repair  as  when 
it  is  left  alone.  Consequently,  when  it  comes  to  the  question 
of  dealing  with  sprains  of  great  severity,  such  as  often  are 
met  with  in  the  ankle,  all  that  is  done,  and,  indeed,  all  that 
can  be  done,  is  to  restore  the  parts  to  the  condition  best  suited 
for  repair,  and  to  guard,  as  far  as  possible,  against  the  after 
troubles  of  stiffness,  chronic  oedema,  and  pain. 

In  older  sprains,  the  method  of  application  is  somewhat 
different.  Here  much  less  stress  is  laid  upon  light  friction,  and 
much  more  upon  deep  manipulation  and  rolling  of  the  parts. 
The  object  is  not  so  much  to  cause  the  absorption  of  a  fluid 
exudation  as  to  stimulate  the  muscles  and  nerves  to  greater 
activity,  and  to  increase  the  amount  of  blood  and  lymph  circu- 
lating through  the  deeper  strata.  The  grasp  is  firmer,  and 
the  pressure  greater;  the  whole  hand  is  used,  and  both  at  the 
same  time;  if,  for  example,  the  limb  is  not  too  large,  one  may 


Sprains ;  their  Consequences  and  Treatment.  131 

be  placed  opposite  the  other,  so  that  two  groups  of  muscles 
are  manipulated  tog-ether,  the  fingers  of  one  hand  partly 
reaching  on  to  the  territory  of  the  other.  One  hand  contracts 
as  the  other  relaxes,  each,  in  its  turn,  squeezing-  the  tissues 
onward  and  away  from  the  middle  line,  and  stretching  the 
parts  that  lie  between  them.  Care,  of  course,  must  be  taken 
not  to  stretch  the  tissues  in  opposite  directions  at  the  same 
time;  and  it  is  a  wise  precaution  to  go  over  the  surface  gently 
and  superficially  before  attempting  deep  or  thorough  manipu- 
lation. 

Where  other  joints  are  concerned,  the  treatment  must  be 
conducted  on  essentially  the  same  principles,  varying  the  de- 
tails according  to  the  circumstances  of  each  case.  The  opera- 
tor should  always  keep  sufficiently  far  off  so  that  his  move- 
ments are  not  cramped  or  constrained,  and  he  should  always 
endeavor  to  make  use  of  as  much  of  the  surface  of  his  hand  as 
possible.  The  fingers  must  be  kept  close  together  for  the  sake 
of  mutual  support;  the}"  should  not  be  allowed  to  slip  too 
much  upon  the  skin,  which  should  move  with  them  as  far  as 
possible,  or  the  operation  may  be  a  very  uncomfortable  one 
for  the  patient.  For  this  reason  ointments  and  other  similar 
applications  are  very  rarely  used  unless  it  is  wished  either  to 
diminish  friction  or  to  produce  some  specific  effect. 

The  patient  must  be  placed  in  an  easy  and  comfortable 
position,  with  the  limb  well  supported,  and,  where  possible, 
well  raised,  so  as  to  assist  the  return  circulation.  If,  for  ex- 
ample, the  wrist  is  the  part  in  question,  the  point  of  the  elbow 
should  be  resting  on  the  table;  if  it  is  the  elbow  itself,  or  the 
shoulder,  the  patient  should  either  rest  his  hand  on  the  shoulder 
of  the  operator,  or  should  even  lay  hold  of  something  higher 
still. 

The  hands  must  always  lie  in  the  direction  of  the  muscular 
fibres,  and  the  rolling  and  squeezing  always  tend  upward 
from  the  extremities  toward  the  trunk.  The  rate  of  move- 
ment and  the  amount  of  force  that  is  used  must  vary  with 
each  individual;  but  there  should  never  afterward  be  am- 
sign  of  bruising  due  to  the  manipulation.  It  is  always  pres- 
ent, of  course,  to  a  greater  or  less  extent,  in  recent  sprains,  and 
it  is  nearly  certain  to  be  there  if  adhesions  are  broken  down 
or  a  joint  is  forcibly  manipulated  under  an  anaesthetic;  but  it 
never  occurs  after  massage  unless  the  force  used  has  been  ex- 


I32  Sprains ;  their  Consequences  and  Treatment. 

cessive  and  unjustifiable,  and  its  presence  generally  means 
that  more  harm  than  good  has  been  done.  Instead  of  assist- 
ing-  in  the  repair  of  the  damage  it  has  inflicted  more. 

It  is  most  essential  to  commence  as  gradually  and  as  gently 
as  possible,  only  working  on  the  deeper  tissues  after  the  more 
superficial  ones  have  become  thoroughly  accustomed,  and  have 
been  unloaded  of  their  surplus  fluid.  The  skin,  the  soft  subcu- 
taneous tissue,  the  muscles,  and  the  deeper  layers,  must  all 
be  worked  in  turn.  Nor  should  the  manipulation  be  confined 
to  the  injured  part.  In  a  sprain  of  any  standing  the  whole  of 
the  limb  is  affected  more  or  less.  It  is  usually  better  to  de- 
vote attention  first  to  the  parts  nearer  the  trunk,  than  to  deal 
with  those  around  the  injured  area,  and  only  afterward,  when 
the  circulation  is  thoroughly  re-established,  to  manipulate  the 
joint  itself. 

The  tendency  is  to  make  the  sittings  last  too  long.  Deep 
manipulation  itself  rarely  requires  more  than  five  minutes; 
but  in  dealing  with  a  recent  injury  it  may  be  advisable  to 
spend  a  longer  time  than  this  over  the  friction  and  other  pre- 
paratory measures,  so  that  a  quarter  of  an  hour  soon  passes  by. 
When  the  tenderness  is  very  great,  and  the  amount  of  swelling- 
excessive,  much  longer  than  this  may  be  necessary,  but  short, 
frequently  repeated  sittings  are  of  greater  benefit  than  one 
long  one.  A  skilled  operator,  too,  will  often  effect  more  in 
a  few  minutes  than  an  ordinary  rubber  will  in  as  many  sit- 
tings. 


CHAPTER  XI. 

SPRAINS  OF  TENDONS. 

SPRAINS  of  tendons  are  deserving-  of  as  much  consideration 
as  those  of  joints;  they  are  almost  as  common;  the  changes 
in  the  tissues  are  nearly  as  serious,  and  the  results,  though 
they  vary  a  good  deal,  are  in  many  respects  quite  as  impor- 
tant. Unless  perfect  freedom  of  movement  is  regained,  there 
is  an  amount  of  suffering-  and  inconvenience  often  altog-ether 
out  of  proportion  to  the  extent  of  the  mischief. 

Structure. — In  one  respect  the  question  is  much  easier; 
the  structures  concerned  are  not  nearly  so  complicated.  The 
shorter  tendons  are  merely  unyielding-  bands  of  various  shape, 
directly  connecting-  the  muscle  to  one  of  the  adjacent  bones. 
They  are  formed  of  tough  fibrous  tissue,  continuous,  on  the  one 
hand,  with  the  membrane  investing  the  bone,  and,  on  the 
other,  spread  out  to  receive  the  attachment  of  the  muscular 
fibres.  The  longer  ones  are  more  or  less  rounded  in  shape, 
and  are  inclosed  in  a  synovial  sheath,  practically  identical  with 
that  which  lines  the  interior  of  joints.  The  surface  is  as  smooth 
as  it  can  be,  so  that  the  tendon  glides  without  friction  in  its 
groove,  no  matter  how  many  bends  or  curves  it  makes,  or  how 
often  the  position  and  direction  of  these  vary  in  different  move- 
ments of  the  limb.  The  interior  is  lubricated  by  a  fluid  identi- 
cal in  character  with  that  in  joints,  just  sufficient  in  amount 
to  fill  up  all  the  interstices,  and  enable  the  sheath  to  fit  closely 
and  evenly  round  the  tendon.  The  outer  wall  is  formed  of 
a  fibrous  layer,  which,  though  apparently  distinct  (just  as  the 
capsule  of  a  joint  appears  distinct),  is  only  a  layer  borrowed, 
as  it  were,  from  the  delicate  tissue  round.  Owing  to  the  fric- 
tion, this  is  condensed  into  a  firm  membrane,  smooth  and 
polished  on  its  inner  surface,  but  roug-h  on  the  outside,  where 
it  still  retains  its  connection  with  the  fibrous  tissue  from  which 
it  was  formed. 

In  some  parts  of  the  body  each  tendon  has  a  separate 


!34  Sprains;  their  Consequences  and  Treatment. 

sheath  surrounding1  it  like  a  tube.  At  the  ends  this  is  con- 
tinuous with  the  sides  of  the  tendon,  so  that  the  cavity  is  com- 
pletely closed.  It  is  largest  and  best  developed  where  there 
are  projecting  points  of  bone,  and  where  the  direction  of  the 
pull  is  consequently  altered.  In  many  parts  the  sheaths  of 
two  tendons  lying1  side  by  side  communicate  with  each  other; 
and  where,  as  an  the  wrist  or  ankle,  the  number  of  those  run- 
ning1 in  the  same  direction  is  considerable,  there  is  only  one 
large  sac  surrounding1  them  all.  Sheaths  of  this  description 
are  much  stronger  and  stouter,  the  walls  are  thicker,  and 
owing  to  the  bundles  of  tendons  lying  side  by  side,  each  move- 
ing  independently  of  the  rest,  are  ribbed,  as  it  were,  on  the 
inner  surface  with  longitudinal  ridges,  wrhich  sometimes  pro- 
ject as  actual  folds,  inclosing  between  their  layers  a  mass  of 
soft  and  delicate  tissue  well  supplied  with  minute  vessels.  In 
the  young  the  lining  membrane  itself  is  quite  smooth,  so  far 
as  its  inner  surface  is  concerned;  but  as  age  advances,  par- 
ticularly in  those  whose  work  is  laborious,  or  whose  joints  and 
tendons  are  exposed  to  heavy  or  repeated  strains,  it  undergoes 
great  alterations.  The  folds  grow  stouter  and  longer,  their 
free  margin  becomes  irregular  and  broken  up  into  fringes,  and 
the  tissue  of  which  they  are  composed  becomes  tougher  and 
firmer,  until  in  some  instances  the  surface  is  as  irregular  and 
as  shaggy  with  villous  processes  as  the  interior  of  a  joint 
affected  with  chronic  synovitis. 

Effects  of  Age. — This,  however,  is  not  the  only  alteration 
found  in  tendon  sheaths  after  adult  life.  There  is  a  slight  but 
constant  tendency  for  them  to  enlarge  and  encroach  on  sur- 
rounding structures.  Where  two  lie  side  by  side,  or  where 
one  is  in  contact  with  the  capsule  of  a  joint,  the  dividing  wall 
in  course  of  time  grows  thinner  and  thinner  until  it  gives  way 
altogether,  so  that  the  cavities  communicate  with  each  other. 
In  other  instances,  where  the  tissues  round  are  soft  and  yield- 
ing, the  sac  expands  unevenly,  and  becomes  covered  over  with 
irregular  dilatations.  If  the  wall  is  especially  weak  at  any 
one  spot,  or  if  from  some  accident  the  fibrous  layer  of  the 
sheath  has  been  torn,  the  lining  membrane  is  forced  out  little 
by  little  into  the  interspace,  until  it  assumes  the  shape  of  a 
pouch,  opening  into  the  sheath  by  means  of  a  long  and  some- 
times very  narrow  neck.  When  one  of  these  is  once  formed  it 
generally  continues  to  increase  in  size.  Fluid  is  driven  into  it 


Sprains ;  their  Consequences  and  Treatment.  135 

with,  very  considerable  pressure  every  time  the  tendon  moves 
without  there  being1  any  corresponding-  force  to  insure  its 
return;  the  sac  grows  larger  and  larger  until  it  projects  be- 
neath the  skin,  or  even  opens  up  a  communication  with  some 
more  distant  cavity.  It  is  in  this  way  that  tendon  sheaths 
become  connected  with  neighboring1  joints,  the  pouch  devel- 
oping- originally  sometimes  from  the  one,  sometimes  from  the 
other. 

In  the  majority  of  instances  it  is  difficult  to  say  how  far 
these  changes  are  the  result  of  time  alone,  and  how  far  they 
are  the  product  of  repeated  sprains,  and  of  attacks  of  rheu- 
matic gout.  In  joints  there  is  no  question  that  these  causes 
are  of  material  assistance,  to  say  the  least.  Whenever  large 
diverticula  are  present,  or  the  interior  of  the  synovial  mem- 
brane is  more  than  usually  irregular,  one  or  other  of  these  has 
been  at  work.  The  same  is  probably  true  of  tendon  sheaths 
and  of  bursse;  the  alterations  are  not  serious  except  under 
these  conditions.  Slighter  degrees,  however,  tending  in  the 
same  direction,  but  not  going  further  than  a  moderate  amount 
of  dilatation  and  thickening,  are  so  common,  and  so  consistent 
with  what  takes  place  under  the  same  conditions  in  similar 
structures,  that  there  is  no  doubt  they  are  due,  in  part  at 
least,  to  the  natural  degeneration  of  the  tissues  occurring 
everywhere  as  age  advances. 

Extent  o/  Injury. — The  tendons  themselves  rarely  sustain 
much  injury  in  the  case  of  sprains.  They  are  formed  of  little 
more  than  tough  bundles  of  fibrous  tissue  closely  woven  to- 
gether, so  that  if  they  escape  being  torn  in  two,  or  wrenched 
from  the  muscle  to  which  they  belong,  they  generally  escape 
altogether.  The  sheaths,  however,  in  which  they  lie  make  up 
for  them  in  this  respect.  They  are  so  delicate  in  structure  £hat 
they  are  torn  or  bruised  by  the  least  unusual  strain,  and  the 
relation  they  bear  to  the  tendon  they  inclose  is  so  accurate 
that  the  slightest  alteration  is  sufficient  to  produce  a  very- 
considerable  effect. 

Overwork. — Serious  consequences  are,  of  course,  much 
more  likely  to  be  produced  by  violent  injuries,  but  mere  over- 
work is  sufficient  to  affect  the  synovial  lining  and  to  cause  in- 
convenience and  actual  pain.  It  need  not  be  excessive;  it  is 
enough  that  it  should  be  more  than  usual,  and  that  it  should 
be  kept  up  for  some  time.  Instances  of  this  are  of  every-day 


136  Sprains ;   their  Consequences  and  Treatment. 

occurrence  when  an  unusual  degree  of  exertion  falls  on  a  group 
of  muscles  that  are  not  accustomed  to  it.  The  movements  of 
the  tendons  are  no  longer  easy  and  natural ;  a  hot,  burning- 
sensation  is  felt  each  time  the  muscle  contracts;  there  is  a 
feeling  of  tenderness  and  fullness  over  it;  the  temperature 
(as  taken  by  a  surface  thermometer)  may  even  be  slightly 
raised,  probably  from  the  larger  amonut  of  blood  that  is  flow- 
ing through  the  part;  and,  what  is  the  most  striking  and 
characteristic  symptom  of  all,  as  the  tendon  plays  backward 
and  forward  in  its  sheath  there  is  communicated  to  the  finger 
a  delicate  sense  of  crepitation  and  rustling",  as  when  two  sur- 
faces of  silk  are  being  rubbed  tog-ether.  Sometimes  this  is 
perceptible  to  the  patient  himself,  at  others  it  can  only  be 
elicited  by  carefully  applied  pressure  over  the  tendon  sheath. 
Whenever  it  occurs  it  may  be  accepted  as  clear  proof  that 
there  is  some  alteration  in  the  relation  between  the  tendon 
and  the  membrane  round  it.  Naturally  it  can  be  felt  most 
plainly  where  a  number  lie  close  together  beneath  the  skin,  as 
on  the  front  of  the  ankle  joint  or  the  back  of  the  hand.  In 
situations  such  as  these,  any  unaccustomed  degree  of  exertion, 
walking,  for  example,  some  distance  unusually  fast,  or  feather- 
ing- in  rowing-  at  the  commencement  of  the  season,  or  even  car- 
rying a  heavy  weig-ht  in  the  hand,  is  sufficient  to  cause  it. 

Tenosynovitis. — It  has  been  imagined  by  some  that  this 
peculiar  sensation  is  the  result  of  the  sheath  becoming  dry. 
The  synovial  fluid  is,  as  it  were,  used  up,  and  the  movement  of 
the  tendon  over  the  dry  and  roughened  surface  causes  friction. 
It  is  very  difficult  to  understand  how  this  can  occur;  such  a 
condition  of  thing-s  would  be  almost  unique ;  nowhere  else  does 
use,  even  when  carried  to  the  greatest  excess,  entail  any  simi- 
lar result.  The  immediate  effect  of  muscular  contraction  is  to 
increase  very  larg-ely  the  amount  of  blood  flowing  through  the 
part,  and  to  cause  a  much  larger  quantity  of  lymph  to  pour 
out  through  the  walls  of  the  vessels  into  the  surrounding  tis- 
sue spaces.  It  is  difficult  to  understand  how,  under  such  con- 
ditions, the  sac  of  the  synovial  membrane  could  become  dry. 
The  walls  contain  a  greater  amount  of  blood,  they  are  softer 
and  thicker,  the  lining  layer  of  cells  is  not  so  perfect,  their 
growth  is  more  rapid,  so  that  they  have  no  time  to  assume 
their  normal  flattened  shape,  and  the  character  of  the  fluid  in 
the  interior  is  modified  by  being  mixted  with  the  exuded  lymph 


Sprains ;   their  Consequences  and  Treatment.  137 

and  with  the  cast-off  cells;  but  the  quantity  is  rather  increased 
than  diminished. 

Lawn  Tennis  Arm. — The  same  symptoms  (with  the  excep- 
tion of  the  rustling1)  are  produced  by  over-exertion  when  the  ten- 
don is  attached  directry  to  bone  without  the  presence  of  any  in- 
vesting- sheath  of  synovial  membrane.  A  common  instance  of 
this  is  met  with  in  a  variety  of  what  it  is  the  present  fashion 
to  call  lawn-tennis  arm,  though  a  similar  thing-  Avas  described 
long-  since  in  Australian  dig-g-ers.  There  is  a  tender  spot  about 
the  middle  of  the  forearm,  on  the  outer  side  of  the  bone,  cor- 
responding- to  the  attachment  of  one  of  the  muscles  that  is 
used  especially  in  back-handed  strokes;  and  sometimes  the 
tenderness  is  so  great  that  I  have  known  it  the  source  of  great 
uneasiness.  The  skin  appears  slightly  swollen  and  raised 
above  the  normal  level ;  but  it  is  quite  white,  even  whiter  than 
the  surrounding-  part,  and  the  swelling-  so  soft  that  it  can  be 
appreciated  much  better  by  the  eye  than  by  the  touch.  In 
moderate  cases  it  is  limited  to  this  point,  and  the  muscle  itself 
is  not  affected ;  only  when  it  contracts  there  is  a  feeling  of 
soreness  and  stiffness,  not,  perhaps,  amounting-  to  actual  pain. 
In  severe  ones  the  swelling-  extends  over  the  whole  muscle. 

The  changes  here  are  essentially  the  same;  owing  to  the 
increased  wear  and  tear  more  blood  flows  through  the  part ;  a 
larger  amount  of  exudation  is  poured  out  into  the  tissues, 
through  the  walls  of  the  vessels ;  the  skin  becomes  more  highly 
sensitive,  so  that  it  feels  sore  and  tender  when  even  light 
pressure  falls  on  it;  and  the  action  of  the  muscles  is  difficult 
and  painful.  Only  there  is  no  crepitation  or  rustling,  because 
there  is  no  synovial  sheath  in  which  the  fluid  can  collect. 

Muscular  Strains. — Under  some  circumstances  the  exer- 
tion required  to  produce  such  a  result  may  be  exceedingly 
trivial.  It  is  not  uncommon  for  patients  who  are  recovering 
from  an  attack  of  severe  illness,  when  they  are  allowed  to  sit 
up  for  the  first  time,  to  complain,  after  an  hour  or  two,  of  sore- 
ness over  certain  bony  prominences,  and  of  a  sensitiveness  of 
skin  that  is  sometimes  mistaken  for  hysteria.  There  is  a  line, 
for  example,  at  the  back  of  the  head,  or  a  space  between  the 
shoulder  blades,  where  the  least  pressure  is  painful,  especially 
after  they  have  been  sitting  up  some  time.  In  the  morning,  or 
after  a  long  rest,  nothing  of  the  kind  is  felt;  the  muscles  can 
act  freely  and  naturally.  It  is  only  when  they  are  tired  out 


138  Sprains ;   their  Consequences  and  Treatment. 

that  these  symptoms  begin  to  appear.  The  work  that  they 
are  called  upon  to  perform  is  too  much  for  them;  they  have 
been  weakened  to  such  an  extent  by  prolonged  illness  and 
want  of  exercise  that  the  exertion  of  sitting-  uprigiit  is  as  much 
out  of  proportion  to  their  strength  as  severe  and  prolonged 
labor  would  be  if  they  were  in  good  training.  There  is,  it  is 
true,  no  appreciable  amount  of  swelling,  but  it  is  quite  suffi- 
cient for  the  purpose  that  the  tender  points  of  bone  correspond 
with  very  fair  accuracy  to  the  attachments  of  the  muscles 
that  receive  the  strain.  Rest  at  once  relieves  it,  and  as  the 
nutrition  improves  and  strength  returns  the  symptoms  rap- 
idly disappear. 

The  same  thing  is  frequently  met  with  in  connection  with 
the  abdominal  muscles  after  vigorous  efforts  of  any  kind,  and 
it  is  sometimes  so  marked  that  I  have  known  it  mistaken  for 
more  serious  disorders,  especially  as  the  muscles  are  often 
thrown  into  a  state  of  cramp,  so  that  they  do  simulate,  to 
some  extent,  internal  tumors.  There  is  the  same  burning  sen- 
sation when  contraction  takes  place;  the  skin  feels  tender  and 
sore,  and  its  sensitiveness  is  extreme  (as  it  frequently  is  in 
hysteria),  the  patient  wincing  at  the  slightest  contact.  Some- 
times the  feeling  of  soreness  is  worst  over  the  points  where  the 
muscles  are  attached  to  the  bone ;  but  more  often  the  patient 
refers  it  to  the  junction  of  the  muscular  and  tendinous  fibres ; 
and  it  is  remarkable  and  very  characteristic  of  this  muscular 
overwork,  that  nearly  always,  in  indicating  the  seat  of  the 
pain,  the  patient  moves  his  hand,  quite  unconsciously,  in  the 
direction  of  the  fibres  that  have  had  the  severest  strain. 

Injury  to  the  Sheaths  of  Tendons. — In  sprains,  however, 
the  trouble  is  generally  more  serious,  and  the  symptoms  more 
definite.  When,  for  example,  a  man  falls  down  with  his  hand 
and  forearm  doubled  up  beneath  him,  so  that  the  whole  of  the 
stress  falls  on  the  tendons  at  the  back  of  the  wrist,  and  the 
soft  and  delicate  tissues  lying  underneath  are  crushed  against 
the  bone,  the  amount  of  damage  sustained  is  not  to  be  mis- 
taken. Within  a  very  few  minutes  the  wrist  swells  up,  the 
tissues  are  bruised,  the  vessels  torn  across,  and  blood  poured 
out  into  the  tendon  sheaths  and  the  structures  round,  just  as 
it  is  when  any  other  part  of  the  body  is  injured.  Only  because 
there  is  a  sac  in  which  the  fluid  can  collect,  the  swelling  is 
unusually  rapid  in  making  its  appearance,  and  is  limited  at 


Sprains ;  their  Consequences  and  Treatment.  139 

first  in  shape.  Soon,  however,  it  begins  to  spread;  the  back 
of  the  hand  swells  up,  though  here  it  always  feels  softer  than 
it  does  elsewhere ;  then  it  extends  along  the  forearm,  and  even 
makes  its  appearance  on  the  front  of  the  wrist,  probably  be- 
cause the  tissues  in  this  situation  were  crushed  and  squeezed  at 
the  moment  of  the  fall.  The  skin  becomes  hot  and  tender; 
movement  at  the  wrist  is  completely  lost;  the  joint  is  kept 
nearly  straight,  and  can  neither  be  bent  nor  extended;  the  for- 
mer movement  is  too  painful,  because  then  the  extensor  tendons 
are  pressed  against  the  part  of  their  sheath  that  has  already 
sustained  the  severest  hurt;  the  latter  is  almost  impossible, 
as  tendons  cannot  work  when  their  sheath  is  distended  with 
fluid.  Even  the  fingers  suffer  in  the  same  way;  though  a  cer- 
tain amount  of  flexion  is  permitted,  they  cannot  be  bent  into 
the  palm  of  the  hand  or  completely  straightened  out. 

After  a  few  days  the  bruise  begins  to  come  out  near  the 
elbow  (generally  on  the  front  surface  of  the  joint)  and,  per- 
haps, in  the  hand;  the  coloring  matter  from  the  blood  soaks 
by  degrees  into  all  the  surrounding  structures,  and  spreads 
along  the  looser  planes  of  cellular  tissue  until  it  reaches  the 
skin.  The  swelling  slowly  diminishes,  remaining  longest  over 
the  tendons ;  the  tenderness  becomes  more  definitely  localized, 
being  chiefly  felt  over  that  part  of  the  back  of  the  wrist  which 
corresponds  to  the  spot  where  the  tendons  were  most  bent  and 
crushed  against  the  edge  of  the  bone ;  the  movement  becomes 
more  free;  the  amount  of  grating  and  creaking  grows  less 
and  less,  and  if  no  adhesions  have  formed,  and  there  are  no 
other  troubles  to  hinder  the  progress  of  recovery,  voluntary 
power  slowly  comes  back,  though  even  in  a  moderately  suc- 
cessful case  it  is  sometimes  months  before  all  the  thickening 
has  disappeared  and  the  joint  can  be  completely  flexed. 

Inflammation. — Sometimes  it  happens  that  instead  of  the 
extravasated-  blood  being  absorbed,  and  the  movements  re- 
turning in  this  way,  inflammation  sets  in  either  as  the  result 
of  some  constitutional  predisposition,  such  as  gout,  or  from 
the  excess  of  tension  in  the  tissues.  Ordinarily  speaking,  it  is 
not  present  at  all.  The  changes  which  have  been  described 
above  are  identical  with  those  that  accompany  any  severe 
bruise;  the  swelling  has  been  already  accounted  for;  the  in- 
creased amount  of  blood  flowing  through  the  part,  causing  the 
skin  to  become  hot  and  sometimes  red.  and  making  it  at  the 


14°  Sprains ;  their  Consequences  and  Treatment. 

same  time  more  sensitive  to  pressure,  is  only  what  is  required 
by  the  increase  in  the  need  for  repair;  the  pain  is  due  to  the 
tension  caused  by  the  extravasation  and  effusion;  and  the  loss 
of  mobility  is  the  result  in  the  early  stages  of  the  distention  of 
the  sheath  (for  unless  the  tendon  is  tightly  grasped  it  loses  all 
its  power)  and  of  the  pain  when  the  torn  and  bruised  tissues 
are  pressed  on;  in  the  later  ones,  of  the  imperfect  absorption 
of  the  lymph  that  has  been  thrown  out  and  of  the  stiffness 
caused  by  prolonged  rest.  These  are  the  great  causes  of  the 
delayed  convalescence  and  of  the  obstinate  rigidity  that  so 
often  follow  such  injuries.  In  the  majority  of  instances  there 
is  no  more  inflammation  after  these  than  there  is  after  a  sim- 
ple fracture  or  a  severe  bruise. 

When  it  does  break  out  the  severity  of  the  symptoms  is 
not  easily  mistaken.  The  pain  is  intense;  it  is  no  longer  a 
question  of  a  hot  or  burning  sensation  felt  when  an  attempt  is 
made  to  move  the  tendon;  the  whole  extremity  throbs  from 
one  end  to  the  other.  The  temperature  rises  rapidly ;  the  skin 
grows  red,  and,  if  suppuration  is  going  to  follow,  becomes 
thick  and  swollen,  so  that  it  pits  on  pressure  and  can  no 
longer  be  raised  up  from  the  structures  that  lie  beneath.  At 
the  same  time  there  is  high  fever,  with  headache  and  constitu- 
tional symptoms  of  great  severity. 

Inflammation  of  this  description  rarely  remains  limited  to 
the  space  in  which  it  begins.  Sheaths  of  tendons  and  bursce 
are,  so  far  as  their  development  is  concerned,  merely  great  in- 
terspaces in  the  cellular  tissue,  and  they  never  lose  their  con- 
nection with  the  others  around  them.  If  they  become  in- 
flamed, and  their  contents  suppurate,  the  way  lies  open  for  the 
pus  to  spread  through  all  the  cellular  tissue  of  the  limb.  It 
may  even  extend  into  the  neighboring  joints  without  there 
being  of  necessity  any  direct  or  open  communication  between 
them.  I  have  many  times  seen  complete  destruction  of  an 
articulation,  even  of  such  a  one  as  the  knee,  occur  as  a  result 
of  deep-seated  suppuration  that  had  found  its  starting-point 
in  the  inflammation  of  a  neighboring  bursa  or  tendon  sheath. 

Imperfect  Recovery. — Imperfect  recovery,  stiffness,  and 
loss  of  power  are  much  more  common.  For  a  week  or  two 
everything  goes  on  well;  the  symptoms  gradually  diminish  in 
severity;  the  pain  becomes  less  and  less;  the  swelling  disap- 
pears, except  immediately  over  the  tendons  (there  it  always 


Sprains ;  their  Consequences  and  Treatment.  141 

lasts  the  longest),  and  a  certain  amount  of  voluntary  move- 
ment is  regained.  But  then  the  improvement  stops.  Every 
attempt  at  further  progress  is  checked  at  once  by  pain,  and  is 
followed  by  an  increase  in  the  swelling.  The  muscles  begin  to 
waste;  the  neighboring  joints  and  tendons  become  stiff  from 
prolonged  disuse;  and  sometimes  the  improvement  already 
won  is  lost  again,  and  free  movement  of  the  tendons  never  re- 
turns completely. 

There  is  no  doubt  that  this  is  much  more  likely  to  happen 
if  the  tendon  sheath  has  been  inflamed,  and  that  then  the  re- 
sults are,  generally  speaking,  much  more  serious.  Even  when 
it  subsides  fairly  soon,  inflammation,  if  it  once  involves  a  ten- 
don sheath,  always  leaves  behind  it  extensive,  and  sometimes 
permanent,  changes.  But  it  is  also  certain  that  loss  of  move- 
ment, and  other  troubles,  are  met  with  after  injuries  of  ten- 
dons in  which  inflammation  never  occurs  at  all.  Complete 
and  permanent  wasting  of  the  muscles,  and  an  absolute  degree 
of  rigidity,  may  be  uncommon;  but,  independently  of  these, 
sprains  are  liable  to  be  followed  by  a  number  of  other  conse- 
quences, which  have  nothing  to  do  with  inflammation,  and 
which  are  quite  sufficient  to  give  rise  to  the  gravest  incon- 
venience, and  even  to  prolonged  suffering. 

Stiffness,  for  example,  is  rarely  absent  altogether.  Some 
time  always  passes  before  the  tendons  move,  as  they  ought  to 
do,  so  easily  that  there  is  no  consciousness  of  their  existence. 
Pain  is  equally  common,  and,  indeed,  is  in  general  severe  in  pro- 
portion to  the  stiffness.  It  differs  immensely  in  different  cases. 
In  some  there  is  a  constant  sense  of  aching,  and  of  soreness 
over  the  whole  part,  even  when  it  is  at  rest.  In  others  it  is 
only  felt  on  movement,  and  then  with  great  severity  over  cer- 
tain spots.  Swelling  nearly  always  persists  for  a  time.  The 
sheath  is  distended  with  fluid,  or  cysts  develop  in  connection 
with  it ;  or  there  is  some  effusion  into  the  cellular  tissue  round, 
sometimes  soft  and  yielding,  at  others  hard  and  irregular.  It 
may  continue  without  material  change  for  an  almost  indefinite 
time;  more  often  it  increases  slightly  in  amount  as  often  as 
the  tendon  is  much  used.  The  skin  may  remain  exceedingly 
tender,  especially  over  those  spots  where  the  swelling  is 
greatest,  or  where  pain  is  felt  when  the  tendon  is  moved. 
Creaking  and  grating  are  almost  universal.  It  is  not  merely 
the  delicate  rustling,  already  mentioned,  due  to  the  alteration 


142  Sprains ;   their  Consequences  and  Treatment. 

in  the  lining  cells,  or  to  blood  or  lymph  being1  mixed  with  the 
synovia,  but  a  much  rougher,  coarser  sound,  caused  by  the 
presence  of  fringes,  projecting  up  from  the  folds  of  the  lining 
membrane,  like  those  in  joints;  or  else  by  myriads  of  loose 
bodies  floating  about  in  the  fluid,  in  which  the  tendon  lies  and 
moves.  Louder  noises  even  may  be  audible  in  the  later  stages, 
caused,  in  all  likelihood,  by  the  sudden  separation  of  two  sur- 
faces that  accurately  fit  each  other. 

Very  often  there  is  a  peculiar  feeling  of  weakness — not  so 
much  actual  loss  of  power  in  most  cases  as  a  sense  of  inse- 
curity. It  occurs  even  with  an  ordinary  ganglion  on  the  back 
of  the  wrist,  and  is  almost  invariable  when  one  of  these  is 
large  enough  to  project  distinctly  under  the  skin.  The  patient 
complains  of  inability  to  use  the  hand,  the  flexor  muscles  being 
as  much  interfered  with  as  the  extensor,  owing,  no  doubt,  to 
the  way  in  which  they  are  always  trained  to  act  together. 
When  the  dilatation  involves  the  sheath  itself,  the  sensation  is 
never  wanting.  I  have  seen  an  instance  in  which  a  patient 
was  quite  unable  to  bend  his  middle  finger,  merely  because  the 
sheath  of  the  flexor  tendons  along  the  under  surface  was  dis- 
tended with  fluid.  There  was  no  other  obstacle ;  it  could  be 
bent  by  the  other  hand,  as  far  as  mechanical  considerations 
would  allow;  and  as  soon  as  the  fluid  was  removed  by  subcu- 
taneous puncture,  full  power  was  regained. 

Even  this  does  not  exhaust  the  list.  There  are  other  con- 
sequences following  sprains  of  tendons,  similar  to  those  already 
described  in  the  case  of  joints,  involving  parts  that  have  not 
sustained  any  direct  injury.  Wasting,  rigidity,  and  loss  of 
power  in  neighboring  muscles;  stiffening  of  the  capsules  and 
sheaths  of  other  joints  and  tendons;  filling  up  of  the  cavities 
of  bursse  and  other  periarticular  spaces;  and  many  others 
which  are  probably  the  result  of  prolonged  rest  and  confine- 
ment in  one  position,  rather  than  of  anything  else.  Inflam- 
mation, when  it  does  break  out,  makes  them  all  tenfold  worse; 
tout  it  is  not  by  any  means  necessary  for  their  occurrence. 
The  injury  sustained  when  a  tendon  sheath  is  badly  bruised, 
and  then  kept  perfectly  quiet  for  an  indefinite  length  of  time, 
is  quite  sufficient  to  account  for  them  in  most  cases  without 
calling  in  the  aid  of  anything  else. 

Treatment. — So  far  as  general  principles  are  concerned,  the 
treatment  of  tendons,  after  they  have  been  sprained,  is  very 


Sprains;  their  Consequences  and  Treatment.  143 

similar  to  that  already  described  in  the  case  of  joints.  The 
great  object  is  to  restore  the  power  of  voluntary  movement 
as  soon  as  possible;  everything  else  must  be  subordinate  to 
this.  Until  this  is  perfect,  recovery  cannot  be  said  to  be  com- 
plete. 

The  first  obstacle  is  the  extravasation  of  blood  into  the 
tissues,  and  the  amount  of  lymph  poured  out  afterward  to 
effect  the  repair  of  the  injury.  The  soft  and  vascular  tissues, 
some  of  the  most  delicate  in  the  body,  are  crashed  and  torn ; 
blood  flows  out  in  all  directions,  until,  if  it  is  not  checked  in 
some  way,  the  sheath  and  the  cellular  spaces  round  can  con- 
tain no  more.  Then  all  the  vessels  dilate;  everything1  swells 
up  and  becomes  soft ;  the  interstices  in  all  directions  are  dis- 
tended with  lymph,  which  gradually  takes  the  place  of  the 
blood  as  this  is  absorbed ;  and  if  no  steps  are  taken  to  prevent 
such  a  result,  the  tendon,  its  sheath,  the  delicate  tissues  round, 
and  even  the  neighboring-  muscles  and  fasciae,  so  far  as  the  in- 
jury has  extended,  become  glued  together.  Of  course,  the  ex- 
tent to  which  this  change  takes  place  in  the  different  tissues 
varies  within  very  wide  degrees.  The  tough,  unyielding,  and 
almost  non-vascular  substance  of  which  a  tendon  is  composed 
scarcely  shows  the  change  at  all,  while  the  soft  and  delicate 
tissue  round  and  between  the  folds  of  the  synovial  sheath  is  so 
altered  that  it  can  hardly  be  recognized;  but  the  principle  is 
the  same.  The  change  is  an  essential  one,  the  natural  conse- 
quence of  the  injury,  and  has  nothing  to  do  with  inflammation. 
Under  certain  conditions  it  may  be  carried  to  excess,  and  then 
it  becomes  a  source  of  danger,  and  may  even,  by  the  help  of 
other  agencies,  become  the  starting-point  of  this  complication, 
the  cause  rather  than  the  consequence.  But  this  ought  never 
to  happen,  and  if  the  effusion  can  be  restrained  within  proper 
limits,  and  the  predisposing  causes  are  not  too  strong,  never 
does  happen.  No  doubt  inflammation  follows  if  a  patient,  who 
is  on  the  verge  of  an  attack  of  gout,  by  some  fall,  strains  or 
otherwise  injures  one  of  his  tendons.  It  is  only  natural  that 
it  should,  and  it  may  come  on  within  an  hour  after  the  acci- 
dent, but  it  is  not  fair  to  put  this  down  entirely  to  the  credit 
of  the  injury. 

There  is  another  reason  for  trying  to  check  the  effusion  as 
soon  as  possible.  After  tendons  have  been  sprained  there  is 
always  a  certain  degree  of  stiffness.  This  is  dependent  on 


144  Sprains ;  their  Consequences  and  Treatment. 

many  things,  and  cannot  be  helped  at  first.  But  the  perma- 
nence of  this  stiffness,  and  its  degree,  are  regulated  almost  en- 
tirely by  the  extent  of  the  effusion,  and  by  the  changes  that  it 
undergoes.  If  it  is  slight  and  quickly  reabsorbed,  leaving  only 
so  much  as  is  needed  for  the  repair  of  the  tissues,  perfect  move- 
ment is  recovered  spontaneously;  but  when  it  is  excessive,  and 
all  the  surrounding  structures  are  softened  and  infiltrated, 
this  can  only  happen  under  the  most  favorable  conditions.  As 
a  rule,  much  of  it  becomes  organized;  and  then  all  the  tissues 
are  made  stiff  and  rigid,  and  are  matted  together  by  adhe- 
sions. The  minute  interstices  between  them,  for  the  purpose 
of  allowing  free  and  even  play  of  movement,  are  filled  up. 
Probably  during  life  they  contain  a  semifluid  material,  so  that 
the  structures  on  either  side  can  easily  accommodate  each 
other  in  their  various  movements;  this  quite  disappears.  In 
worse  cases,  the  opposite  surfaces  grow  together,  and  the  ten- 
don becomes  adherent  to  its  sheath,  either  in  places,  here  and 
there,  so  that  fibrous  bands  pass  across  from  one  to  the  other 
and  limit  the  range  of  action,  or  even  all  over,  so  that  recovery, 
so  far  as  movement  is  concerned,  is  quite  hopeless. 

Pressure. — Heat  or  cold  may  be  tried  at  first,  as  already 
directed  in  speaking  of  joints,  but  by  far  the  most  efficacious 
method  is  to  apply  well-graduated  pressure  from  the  very 
commencement.  The  details,  of  course,  must  vary  in  each 
case,  but  when  this  can  be  done  systematically,  not  as  band- 
aging ordinarily  is,  with  the  whole  of  the  pressure  on  the 
bones,  nothing  succeeds  so  well.  Only  there  must  be  a 
thorough  knowledge,  not  only  of  the  structure  and  arrange- 
ment of  the  parts,  but  also  of  the  exact  nature  of  the  injury 
sustained  in  each  case. 

Massage. — Massage  or  kneading  is  even  more  useful  in  the 
treatment  of  sprained  tendons  and  muscles  than  it  is  in  the 
case  of  joints.  The  second  day,  when  the  pads  and  bandages 
are  removed,  the  limb  appears  misshapen  from  the  pressure  to 
which  the  soft  tissues  have  been  subjected,  and  stiff  from  their 
confinement.  Kneading  and  working  the  part  thoroughly 
every  day  causes  this  to  disappear  more  rapidly  and  more 
effectually  than  anything  else.  It  must,  of  course,  be  done 
with  a  definite  idea  of  the  purpose  in  view,  and  with  a  knowl- 
edge of  the  structure  of  the  part  itself.  Further,  as  the  acci- 
dent is  so  recent,  the  ordinary  rules  must  be  observed  with 


Sprains ;  their  Consequences  and  Treatment.  145 

even  more  than  usual  care.  The  rubbing1  at  the  commence- 
ment must  be  very  light,  affecting-  only  the  skin  at  first,  and 
then  later  the  deepest  structures.  Tender  spots  must  be  ap- 
proached very  carefully ;  they  need  even  more  attention  than 
the  rest,  but,  unless  it  is  very  cautions,  manipulation  makes 
them  more  painful  still.  Every  movement  must  be  commenced 
at  the  end  of  the  limb,  working  gradually  toward  the  trunk. 
Properly  managed,  and  used  at  the  same  time  as  passive 
motion,  the  relief  this  gives  is  immense ;  the  pain  is  exceed- 
ingly slight ;  the  swelling-  disappears  more  rapidly  than  it  does 
under  any  other  method,  and  the  chances  of  after  stiffness  are 
materially  lessened. 

Passive  Movement. — There  are  the  same  rales  with  regard 
to  passive  motion.  It  must  be  employed  reg-ularly  and  sys- 
tematically every  day  without  fail.  The  loose  tissues  round 
the  tendon  sheath  are  softened  and  thickened ;  the  surface  of 
the  sj^novial  sac  is  rough  from  the  rapidity  with  which  the 
new  cells  are  formed  to  line  it  in  place  of  the  old  ones;  and  it 
is  irreg-ular  from  the  swelling-  of  its  folds  and  fringes.  Unless 
movement  is  kept  up  from  the  first  this  must  end  in  some  de- 
gree of  stiffness.  It  need  not  be  repeated  often  at  each  sitting-; 
once  is  quite  enoug-h,  but  it  must  be  thorough.  Every  joint 
and  every  tendon  near  the  part  that  has  been  injured  must  be 
worked  at  least  once  a  day  through  its  whole  range  of  action. 
Slight  and  faint-hearted  attempts,  apparent  movements  really 
taking-  place  at  another  joint,  are  useless,  and  throw  discredit 
on  the  treatment.  They  do  not  prevent  the  formation  of  ad- 
hesions, or  break  down  those  that  are  already  established; 
they  merely  pull  and  strain  on  the  stiffened  structures  round, 
and  make  them  painful  and  tender  without  setting-  them  free. 
The  adhesions,  before  they  are  too  firm,  are  easily  separated 
by  definite  and  well-regulated  manipulation  without  any  fear  of 
exciting  inflammation.  Even  after  they  have  become  organ- 
ized it  is  safer,  as  has  already  been  shown  in  speaking  of  joints, 
to  break  them  down  thoroughly  and  effectually  with  one  single 
effort  than  to  keep  perpetually  straining  and  worrying-  them. 
Weak  and  ineffectual  attempts,  carried  on  hap-hazard,  without 
any  definite  object  in  view,  do  more  harm  than  good.  They 
increase  the  pain  that  is  left,  cause  more  lymph  to  be  poured 
out,  prevent  the  absorption  of  that  which  is  already  there,  and 
allow  it  to  accumulate  until,  as  the  adhesions  grow  thicker 


146  Sprains ;  their  Consequences  and  Treatment. 

and  stronger,  the  prospect  of  recovery  becomes  more  remote 
than  ever. 

In  the  later  stages,  when  the  signs  of  cruising  have  nearly 
disappeared,  if  the  movement  of  the  tendons  remains  painful 
and  constrained,  and  particularly  if  the  patient  can  point  out 
certain  spots  which  are  especially  tender  after  use,  more  ener- 
getic treatment  is  required,  just  as  in  cases  of  imperfect  re- 
coverj7  after  sprains  of  other  parts.  Baths,  douching,  and 
shampooing  may  be  tried  with  success  in  many  instances. 
Tendons,  even  when  very  stiff,  nearly  always  move  more  freely 
after  long  soaking  in  hot  water,  and  though  they  may  not  re- 
tain the  whole,  there  is  nearly  always  a  certain  amount  of  per- 
manent improvement.  Galvanism,  too,  in  these  circumstances 
is  sometimes  of  great  assistance  in  encouraging  the  circulation 
and  restoring  muscular  vigor.  Stimulating  liniments,  espe- 
cially those  containing  the  aromatic  oils,  are  also  most  useful  as 
adjuncts.  They  increase  the  flow  of  blood  through  the  super- 
ficial parts,  soothe  the  pain,  and  loosen  and  improve  the  nutri- 
tion of  the  skin.  In  this  way  they  are  of  assistance  to  other 
measures  which  they  cannot  replace.  If  there  are  large  and 
tender  muscular  masses,  which  remain  stiff  and  painful,  acu- 
puncture often  acts  with  good  effect,  as  described  in  speaking 
of  sprains  of  the  back;  and  counter-irritants  and  small  light 
blisters,  often  repeated,  are  of  excellent  service  in  many  of 
these  cases.  If,  however,  the  tender  spots  are  very  definitely 
marked,  and  if  they  become  more  painful  and  tender  regularly 
after  certain  movements,  these  methods  are  rarely  sufficient 
to  secure  more  than  mere  temporary  relief.  Something  further 
is  required. 

More  Permanent  Changes,  Adhesions,  etc. — It  may  be 
that  there  is  the  residue  of  an  old  organized  blood  clot,  outside 
the  sheath  altogether,  forming  a  little  hard,  irregular  mass, 
that  is  pressed  on  in  certain  positions  when  the  tendon  is 
stretched.  I  have  known  this  it  the  neighborhood  of  the  knee, 
in  the  fibrous  expansion  given  off  by  the  extensor  muscle.  It 
was  merely  a  little  blood  clot,  following  a  blow,  lying  under- 
neath the  fibres;  but  probably  there  was  a  nerve  filament 
near  it,  for  the  least  contraction  of  the  muscle  gave  rise  to  an 
amount  of  pain  seemingly  out  of  all  proportion.  I  have  little 
doubt  that  the  same  thing  sometimes  occurs  in  connection 
with  deeper  tendons. 


Sprains ;  their  Consequences  and  Treatment.  147 

In  other  cases  there  is  an  adhesion,  or  some  thickening-  on 
the  tendon  sheath,  or  there  are  fringes  or  loose  bodies  in  the 
interior  continually  shifting-  their  position,  and  keeping-  up  a 
certain  amount  of  effusion,  by  the  way  the  sheath  is  bruised 
when  the  tendon  moves  over  it.  It  is  extraordinary  what  a 
degree  of  pain  and  tenderness  may  be  caused  by  a  body  of 
this  kind,  whether  in  a  tendon  sheath  or  bursa.  Quite  re- 
cently a  patient,  a  woman  of  middle  age,  with  rather  stout 
and  shapeless  limbs,  was  sent  to  me,  complaining  that  she  had 
received  a  blow  on  the  knee  about  a  month  before,  and  that 
ever  since  she  had  suffered  such  an  amount  of  inconvenience 
that  she  could  scarcely  get  about.  Walking  had  become  very 
painful;  going  upstairs  was  bad,  but  coming  down  she  had 
such  a  sense  of  insecurity  that  she  was  obliged  to  cling  to  the 
banisters,  a  statement  which  I  have  often  heard  when  there 
was  anything  interfering  with  the  action  of  the  extensor  of 
the  knee.  On  examining  the  joint,  it  appeared  slightly  en- 
larged, but  most  of  the  swelling  was  below  the  knee-cap  on 
each  side  of  the  ligamentum  patellae,  caused  apparently  by  the 
enlargement  of  the  bursa,  which  exists  naturally  in  this  situa- 
tion, and  which  is  always  larger  and  more  prominent  in  women 
than  it  is  in  men.  It  was  over  this  that  she  had  received  the 
blow,  and  here  on  firm  pressure  could  be  felt  a  large  loose 
body,  which,  when  the  muscle  was  relaxed,  slipped  easily  under 
the  ligament  from  one  side  of  the  joint  to  the  other,  causing 
each  time  a  very  peculiar  and  sickening  sensation. 

In  the  same  way  I  have  on  several  occasions  been  able  to 
trace  the  development  of  foreign  bodies  in  the  bursa  lying  in 
front  of  the  knee-cap.  In  this  situation  they  give  rise  to  little 
inconvenience,  as  a  rule,  until  in  kneeling  down  and  reaching 
forward  the  weight  of  the  body  is  brought  to  bear  upon  the 
patella ;  then  there  is  a  sudden  stab  of  acute  pain,  and  within 
a  few  hours  the  bursa  becomes  filled  with  fluid.  Sometimes 
there  is  only  one,  irregular  in  size  and  shape,  but  often,  owing 
probably  to  the  repetition  of  the  injury  before  advice  is  sought, 
the  number  is  very  considerable;  or  if  the  first  is  due  to  injury, 
the  others  may  result  from  the  persistent  degree  of  irritation, 
and  even  of  inflammation,  maintained  by  its  presence. 

When  the  pain  can  be  traced  definitely  to  a  cause  of  this 
kind,  there  is  no  alternative.  The  patient  must  be  placed 
under  an  anaesthetic  to  avoid  suffering,  and  to  secure  complete 


148  Sprains ;  their  Consequences  and  Treatment. 

muscular  relaxation ;  the  part  must  be  thoroughly  examined, 
and  the  adhesion,  if  one  is  present,  broken  down,  or  the  foreign 
body  removed.  Whatever  the  cause  of  the  continued  tender- 
ness may  be,  it  very  rarely  happens  that  it  is  of  a  nature  to 
be  cured  by  prolonged  rest.  In  the  great  majority  of  instances 
it  is  due  to  this  having  been  too  much  prolonged  already. 
Most  of  the  crippled  joints  and  tendons  that  are  met  with  after 
sprains  are  due*  to  the  fact  that  passive  movement  has  not 
been  employed  sufficiently  early  or  sufficiently  thoroughly;  and 
they  are  only  to  be  cured  by  the  adoption  of  measures  that 
must  be  energetic  in  proportion  to  the  delay. 

Ganglions. — Some  of  these  after-consequences,  ganglions, 
for  example,  require  a  certain  amount  of  notice,  as  they  either 
do  not  occur  in  connection  with  sprains  of  joints,  or,  when  they 
do,  must  be  treated  in  a  special  way.  There  are  two  varieties 
of  these ;  one  is  a  small  cyst,  originally  in  connection  with  the 
sheath,  and  probably  due  in  the  first  place  to  a  protrusion  of 
the  sac  through  a  weakened  or  ruptured  part  of  the  wall;  the 
other  is  a  dilatation  of  the  sheath  itself.  There  is  no  essential 
difference  between  these,  so  far  as  their  origin  is  concerned; 
they  both  frequently  originate  in  strains,  though  it  is  possible 
some  may  arise  from  inflammation  or  in  other  ways;  they 
contain  the  same  kind  of  fluid,  a  clear  gelatinous  substance, 
much  thicker  than  natural,  and  devoid  of  all  lubricating  power; 
and  it  is  often  possible  to  find  transition  forms  between  them,, 
sheaths,  that  is  to  say,  irregularly  distended,  so  that  they 
appear  to  be  sacculated;  but  the  symptoms  to  which  they 
give  rise,  and  the  method  of  treatment  to  be  adopted,  are  very 
different.  The  former  are  by  far  the  most  common,  and  occur 
with  especial  frequency  on  the  back  of  the  wrist,  where  they 
give  rise  to  much  annoyance  by  their  unsightly  appearance, 
and  by  the  sensation  of  weakness  that  accompanies  them. 
They  are  met  with,  however,  as  well  on  the  foot,  on  the  outside 
of  the  knee,  just  by  the  head  of  the  fibula,  and  in  other  places; 
indeed,  there  is  hardly  a  tendon  sheath  in  the  body  from  which 
they  do  not  sometimes  project.  As  a  rule,  the  inconvenience 
they  cause  is  not  serious,  but  it  is  not  uncommon  to  meet  with 
instances  in  which  neuralgic  pain  of  a  severe  character  is  a 
prominent  symptom,  probably  because  some  small  cutaneous 
nerve  happens  to  be  pressed  upon  by  the  cyst  in  certain  posi- 
tions of  the  limb. 


Sprains ;  their  Consequences  and  Treatment.  149 

Simple  Ganglion. — The  ordinary  method  of  treating-  these 
is  to  crush  them  by  direct  pressure,  and  then  gradually  squeeze 
the  contents  into  the  surrounding-  tissues,  so  that  they  may  be 
absorbed,  assisting  the  process  from  time  to  time  by  friction 
and  kneading-,  or  by  the  pressure  of  a  leaden  plate.  Or  they 
may  be  punctured,  and  the  fluid  let  out,  and  if  they  fill  again, 
injected  with  iodine,  or  a  small  seton  passed  through  them.  Or 
a  small  tenotomy  knife  may  be  introduced  on  one  side  of  the 
cyst,  and  the  whole  mass  divided  in  two  by  a  horizontal  cut; 
this  answers  better  than  the  others,  as  it  is  impossible  for  the 
sac,  when  it  has  once  been  treated  in  this  way,  to  fill  again; 
but  none  of  these  methods  are  quite  satisfactory.  They  often 
succeed,  it  is  true;  but,  even  when  the  cyst  does  not  return, 
it  is  very  common  for  a  hard  irregular  mass  to  be  left  behind, 
interfering  with  the  action  of  the  tendons,  and  causing  an  un- 
sightly tumor.  I  have  known  a  swelling  of  this  kind  persist 
unaltered  for  twenty  years  in  spite  of  continued  attempts  by 
kneading-  and  other  measures  to  g-et  rid  of  it. 

When  it  is  desired  to  remove  them  thoroughly  and  finally, 
it  answers  much  better  to  dissect  them  out.  There  is  no  diffi- 
culty unless  they  have  been  ruptured  and  squeezed  several 
times  before;  they  separate  readily  from  everything-  round 
except  the  tendon  sheath.  Generally  they  are  firmly  attached 
to  this,  and  often  when  the  uniting-  band  is  severed  the  tendon 
may  be  caught  sight  of,  lying  in  its  groove,  and  showing-  that 
the  cyst  was  in  communication  with  its  sheath.  If  the  opera- 
tion is  done  carefully,  and  the  hand  kept  on  a  splint  for  a  day 
or  two  after,  the  cure  is  effectual,  and  the  scar  can  scarcely  be 
seen  at  the  end  of  a  week.  If,  however,  the  cyst  has  been 
much  handled  first,  particularly  if  several  unsuccessful  at- 
tempts at  squeezing  it  have  been  made,  it  must  be  left  for 
some  time  before  attempting-  any  such  preceding. 

Compound  Ganglion. — It  is  more  serious  when  the  dilata- 
tion involves  the  sheath  itself,  especially  if  it  is  a  large  com- 
pound one,  including  many  tendons,  such  as  that  in  the  palm 
of  the  hand,  or  if  it  is  in  the  immediate  neig-hborhood  of  a 
joint.  Even  where  there  is  only  a  single  tendon,  and  the  size 
of  the  sheath  is  not  very  great,  the  inconvenience  is  often 
considerable ;  but  in  these  cases  the  character  of  the  wall  rarely 
undergoes  much  change,  and  if  they  are  not  cured  by  blistering 
or  tapping  they  are  certain  to  yield  to  subcutaneous  incision, 


150  Sprains ;  their  Consequences  and  Treatment. 

followed  by  pressure  and  passive  motion.  In  the  larger  ones 
the  lining-  membrane  and  the  contents  have,  generally  speak- 
ing, undergone  such  modifications  that  it  is  often  impossible  to 
promise  more  than  relief. 

Like  the  others,  their  origin  may  sometimes  be  traced  to 
a  single  strain,  though  it  is  more  usual  for  them  to  develop  as 
a  result  of  repeated  injury.  In  proportion  to  their  number, 
communications  with  joints  are  certainly  more  frequent;  but 
this,  of  course,  is  mainly  regulated  by  anatomical  considera- 
tions, and  by  the  condition  of  the  joints  themselves.  If  these 
are  affected  by  rheumatic  gout,  or  if  cysts  develop  from  them 
for  other  reasons,  it  is  all  the  more  likely  to  occur.  Sometimes 
the  connection  is  due,  as  I  have  seen  myself,  to  the  enormous 
size  of  the  ganglion;  it  grows  larger  and  larger  until  the 
structures  in  between  are  so  thinned  by  absorption  that  they 
give  way,  but  more  often,  as  Morrant  Baker  has  shown,  the 
reverse  of  this  happens,  diverticula  form  along  tendon  sheaths, 
or  through  weak  parts  in  the  capsule  of  joints,  and  appear 
perhaps  some  distance  off  as  cysts  which  closely  resemble 
ganglions. 

The  fluid  in  the  interior  may  be  identical  with  that  found 
in  the  smaller  forms,  or  it  may  be  more  liquid  and  less  gelat- 
inous. It  develops  in  a  very  short  space  of  time;  I  have 
found  it  present  and  of  typical  consistence  within  three  weeks 
of  a  strain.  The  wall  is  usually  much  altered  in  character ;  in 
one  instance  it  was  in  a  condition  almost  identical  with  that 
met  with  in  joints  as  a  result  of  strumous  inflammation,  greatly 
thickened,  that  is  to  say,  much  too  vascular,  semi-translucent 
in  appearance,  and  covered  over  on  its  inner  surface  with 
numerous  little  granulations.  In  other  cases  it  is  much  tougher 
and  firmer,  and  projects  into  the  interior  in  great  folds  and 
fringes,  which  lie  between  the  tendons,  and  seriously  interfere 
with  their  action.  Occasionally,  the  sheath  is  divided  into 
chambers,  and  very  often  it  contains  numbers  of  minute  bodies 
of  the  same  shape  and  size  as  melon  seeds.  What  these  are 
formed  of  is  not  absolutely  certain  in  all  cases ;  it  seems  most 
probable  that,  in  the  majority,  they  are  developed  either  from 
the  fibrin  of  extravasated  blood,  or  from  lymph  that  has  col- 
lected in  the  sheath,  and  has  been  worked  continually  back- 
ward and  forward  by  the  movements  of  the  tendons.  When 
they  are  present  in  any  number  the  wall  is,  as  a  rule,  coated 


Sprains ;  their  Consequences  and  Treatment.  151 

over  and  roughened  with  material  of  the  same  character,  so 
that  probably  the  latter  explanation  is  correct.  They  contain 
no  cells  or  fibres ;  on  the  addition  of  acetic  acid  they  swell  up 
so  as  to  become  translucent.  All  that  can  be  made  out  is  an 
indistinct  concentric  marking-,  as  if  they  were  formed  of  layer 
after  layer  of  some  fibrinous  material. 

Ganglions  such  as  these  must  be  treated  on  totally  differ- 
ent principles  to  the  smaller  ones.  Palliative  measures  are  of 
little  use;  free  subcutaneous  division  of  the  wall  has  been 
practiced  with  success  in  some  of  the  simpler  ones,  where  there 
are  no  melon-seed  bodies;  and  in  the  case  of  the  great  palmar 
one,  section  of  the  ligament  that  divides  it  in  two  has  been 
recommended,  but  I  have  had  no  experience  of  it.  Generally 
speaking,  the  sac  must  be  laid  open  freely,  the  whole  of  the 
fluid  removed,  together  with  the  melon-seed  bodies  present, 
any  partitions  that  exist,  dividing  the  interior  into  chambers, 
thoroughly  broken  down,  and  even  in  some  instances  it  is 
necessary  to  scrape  the  wall,  so  as  to  clear  it  from  the  adherent 
lymph.  Then  it  must  be  drained  so  that  it  does  not  refill. 
Naturally  this  operation  is  a  very  serious  one.  There  is  great 
danger  of  inflammation  setting  in,  and  even  if  it  does  not, 
some  permanent  degree  of  rigidity,  in  spite  of  the  early  use  of 
passive  motion,  is  always  left  behind.  If  it  does,  the  conse- 
quences may  be  disastrous  to  the  very  last  degree. 

Cysts  that  develop  in  connection  with  joints,  whether  as  a 
result  of  injury  or  of  rheumatic  gout,  or  of  both  together, 
must  either  be  left  alone  or  treated  in  the  same  way.  In  this 
one  would  be  guided  mainly  by  the  age  and  constitution  of  the 
patient,  the  condition  of  the  joint  as  regards  security  and 
movement,  and  the  size  and  rapidity  of  formation  of  the 
cyst.  I  have  seen  them  in  connection  with  the  shoulder,  ankle, 
and  knees;  and  no  doubt  they  may  occur  in  other  joints  as 
well.  Sometimes  they  caused  but  little  inconvenience;  at 
others  they  spread  so  rapidly,  and  attained  such  a  size,  that 
it  was  absolutely  necessa^  to  drain  them.  In  nearly  all 
there  was  a  great  deal  of  stiffness  afterward,  but  this  was 
due  in  part  to  the  original  disease;  one  of  them  suppurated. 


nO 

i  T  /A  1 0  "  ~        )  3  J  J  Q  0 

x 


CHAPTER  XII. 

SPRAINS  OF  THE  BACK  AND  NECK. 

SPRAINS  of  the  back  and  neck  are  sufficiently  common  and 
important  to  deserve  a  certain  amount  of  separate  considera- 
tion. The  structures  concerned  are  exceedingly  complicated; 
there  is  an  immense  number  of  separate  joints  of  various  shape 
and  size,  and  in  addition  there  is  the  spinal  cord  running-  in  a 
canal  down  nearly  the  whole  of  its  length,  and  giving-  off  the 
nerves  which  pass  out  on  either  side  between  the  bones.  JSTor 
do  the  injuries  themselves  vary  less  in  character  and  severity. 
In  some  they  are  exceedingly  slight;  in  others  the  consequences 
are  as  serious  as  any  that  occur  in  surgery.  Some,  too,  have 
gained  a  most  unenviable  notoriety  from  their  connection  with 
railway  accidents;  for  whatever  may  be  the  truth  as  regards 
many  of  these  cases,  whether  they  are  deceptions  or  not,  there 
can  be  no  question  that  sometimes  very  considerable  injuries 
are  produced  by  the  way  in  which  the  backbone,  and  the 
structures  in  connection  with  it,  are  strained  and  wrenched 
when  the  body  is  thrown  violently  backward  and  forward  as 
it  is  in  collisions. 

One  of  the  most  singular  features  in  connection  with  these 
sprains  is  the  way  in  which  the  backbone  itself,  and  the  mus- 
cular and  ligamentous  structures  around  it,  are  overlooked  and 
ignored.  Even  in  the  ordinary  accidents  of  every-day  life 
there  is  a  great  tendency  to  lay  everything  that  is  serious  or 
lasting  to  the  credit  of  the  spinal  cord.  In  railway  cases  there 
is  no  hesitation  at  all;  if  any  serious  result  ensues  it  must  be 
the  consequence  of  damage  this  structure  has  sustained,  or  of 
inflammation  following  it;  little  or  no  attention  is  paid  to  any- 
thing else.  Yet  it  is  difficult  to  see  why  the  other  structures 
should  enjoy  immunity.  The  vertebral  column  may  be  strained, 
especially  in  the  cervical  and  lumbar  regions;  the  ligaments 
torn  or  stretched;  the  nerves  bruised  or  crushed;  the  smaller 


Sprains ;  their  Conseqtiences  and  Treatment.  153 

joints  between  the  segments  twisted  and  wrenched;  the  mus- 
cles detached  from  their  bed  and  torn  across,  or  thrown  into 
such  a  state  of  cramp  that  they  become  rigid  and  unable  to 
act  with  freedom ;  or  the  fibrous  sheath  which  contains  them 
and  helps  to  secure  the  bones  laid  open  and  filled  with  blood. 
Results,  in  short,  of  the  most  serious  description  are  not  un- 
common, and  often  leave  lasting-  evidence  of  their  existence  be- 
hind, when  the  spinal  cord  itself  escapes  completely. 

Injuries  of  the  Spinal  Cord. — When  it  is  hurt  the  symp- 
toms cannot  easily  be  mistaken.  There  may  be  insensibility 
for  a  time  even  when  the  head  is  not  injured.  A  certain  de- 
gree of  shock  is  always  present,  and  when  this  has  passed  off 
there  is  paralysis  or  loss  of  power,  corresponding  in  extent 
and  degree  to  the  amount  of  injury  sustained.  This  may 
make  itself  apparent  at  once,  or  some  time,  even  hours,  may 
elapse  before  there  is  any  definite  evidence  of  its  presence. 
Sometimes  it  is  so  slight  that  it  can  only  be  detected  by  the 
most  careful  investigation;  at  others  it  is  so  severe  as  to  give 
rise  to  the  suspicion  of  fracture  or  dislocation.  Geiieralhr 
speaking,  when  it  is  due  to  bruising,  or  to  what  is  still  more 
common,  effusion  of  blood  into  the  tissues  round  the  cord  so  as 
to  compress  it,  the  S3rmptoms  begin  to  diminish  at  the  end  of 
a  few  days.  Recovery  may  then  progress  without  interruption 
until  it  is  complete,  or  it  may  be  arrested  at  any  point,  leav- 
ing behind  it  greater  or  less  impairment  of  power.  Sensibility 
is  frequently  affected,  too,  but  it  rarely  suffers  in  anything  like 
the  same  degree.  If  it  is  lost  completely  the  prognosis  must 
be  regarded  as  exceedingly  grave,  for  it  nearly  always  indi- 
cates that  at  some  one  point  the  cord  has  been  crushed  and 
disorganized.  Sometimes  a  certain  amount  of  hyperaesthesia 
or  increased  sensitiveness  of  skin  may  be  detected  over  a  small 
area  immediately  above  the  seat  of  injury,  but  the  general 
tenderness  all  down  the  spine,  which  is  such  a  common  symp- 
tom in  sprains  of  the  back,  whether  they  occur  in  railroad  ac- 
cidents or  elsewhere,  and  the  strange  sensations,  such  as 
crawling,  creeping,  or  tingling,  experienced  in  the  limbs,  are 
probably  due  entirely  to  other  causes.  They  are  certainly 
met  with  in  cases  in  which  there  is  no  reasonable  ground  for 
suspicion  that  the  cord  itself  has  been  hurt  in  any  way. 

Into  this  part  of  the  question,  however,  it  is  not  my  inten- 
tion to  enter  at  present.  Injuries  of  the  spinal  cord,  and  the 


1 54  Sprains ;   their  Consequences  and  Treatment, 

consequences  that  may  result  from  them,  are  matters  much 
too  serious  to  be  regarded  merely  as  complications  of  sprains 
of  the  back,  and  the  subject  has  been  already  exhaustively 
treated  by  Page  in  his  work  on  "  Injuries  of  the  Spine  and 
Spinal  Cord."  My  contention  merely  is  that  a  very  large 
number  of  the  symptoms  which  are  usually  considered  as 
definite  proof  that  the  spinal  cord  has  been  hurt  may  be,  and 
in  a  large  proportion  of  instances  probably  are,  due  altogether 
to  the  injuries  that  the  other  structures  in  the  back  must  sus- 
tain in  such  accidents. 

Injury  to  the  Muscles  and  Ligaments;  Sprains. — S.  C., 
thirty-two  years  of  age,  a  strong,  healthy  man  of  exceptionally 
good  physique,  in  getting  out  of  a  barge  slipped  and  pitched 
head-foremost  into  the  hold  among  some  bales  of  goods.  The 
shock  was  in  a  measure  checked  by  his  hands,  or  he  would 
almost  inevitably  have  broken  his  neck.  As  it  was,  he  lay  for 
some  moments  unable  to  extricate  himself,  with  his  head 
doubled  under  him  and  his  chin  driven  down  upon  his  chest. 
He  did  not  lose  consciousness;  there  was  no  concussion  or 
other  injury  to  his  brain;  there  was  no  fracture  or  dislocation 
anywhere  about  his  spine,  though,  owing  to  the  severity  of  the 
shock  he  had  sustained,  he  was  unable  to  stand  upright,  and  it 
was  almost  certain  that  his  spinal  cord  had  not  suffered  any 
very  serious  hurt,  for  after  he  had  recovered  from  the  shock  he 
was  able  to  move  his  arms  and  legs  about  freely  in  all  directions. 
Sensation  was  not  in  the  least  impaired ;  there  was  no  tingling 
or  feeling  of  pins"  and  needles;  nor  was  there  that  peculiar 
sense  of  constriction  round  the  body  as  if  a  string  were  tied 
round  it,  of  which  so  many  patients  complain.  The  stress  had 
fallen  almost  entirely  on  the  muscles  and  ligaments  at  the 
back  of  the  neck ;  these,  no  doubt,  were  severely  strained,  and 
it  seems  probable  from  what  followed  that  the  nerves  running 
from  the  spinal  cord  had  suffered  in  the  same  way. 

The  next  day  the  shock  had  completely  passed  off.  He 
had  slept  but  little  during  the  night,  and  he  still  felt  giddy, 
everything  seeming  to  go  round  when  he  attempted  to  sit  up- 
right; but  he  had  recovered  his  natural  color  and  expression, 
and  the  pulse  and  temperature  were  perfectly  normal.  He 
had  completely  lost,  however,  the  power  of  moving  his  head 
or  neck;  the  least  attempt,  especially  nodding,  brought  on 
severe  attacks  of  pain,  shooting  up  over  his  head  and  behind 


Sprains;   their  Consequences  and  Treatment.  i$5 

his  ears  on  each  side,  so  that  he  sat  either  with  his  chin  rest- 
ing- on  his  hand,  or  with  his  thumbs  behind  his  ears  and  his 
fingers  grasping-  his  face.  Indeed,  without  support  of  some 
kind  he  seemed  unable  to  hold  his  head  upright.  He  com- 
plained of  his  back  and  neck  feeling  weak,  as  if  he  were  going 
to  be  paralyzed,  mistaking,  as  Hood  has  pointed  out,  the  fear 
of  movement  due  to  the  pain  it  causes  for  actual  loss  of  power. 
The  skin  was  exceedingly  tender  to  the  touch,  as  it  is  over 
every  sprained  joint,  and  there  was  a  certain  degree  of  swell- 
ing, very  ill-defined  in  outline,  over  the  part  that  had  been 
most  severely  strained.  What  caused  him  most  apprehension, 
however,  was  the  difficulty  that  he  felt  in  opening  his  mouth. 
He  could  shut  it  easily  enough,  but  slight  as  is  the  muscular 
effort  required  to  move  it  in  the  opposite  direction,  it  was 
almost  too  much  for  him.  The  muscles  which  act  from  the 
upper  part  of  the  chest,  and  help  to  form  a  fixed  point  from 
which  the  lower  jaw  can  work,  were  unable  to  do  their  fair 
share.  They  had  not  been  injured  themselves,  but  the  nerves 
supplying  them  had  been  strained  in  the  neck  at  the  moment 
of  the  fall,  and  were  unable  to  carry  the  necessary  stimuli. 
For  the  same  reason  his  breathing  was  very  shallow  and  his 
speech  slow  and  deliberate. 

In  a  few  days  this  began  to  pass  away ;  the  sense  of  strength 
returned,  and  movement  became  much  more  easy;  but  for  a 
long  time  a  peculiar  sensation  could  be  detected  in  the  neck 
when  the  head  was  turned  from  side  to  side,  as  if  two  rough- 
ened surfaces  were  being  rubbed  against  each  other,  or  some 
dense  fluid,  such  as  extra vasated  blood,  were  being  squeezed 
to  and  fro  in  the  meshes  of  the  cellular  tissue.  Gradually  this, 
too,  disappeared,  but  in  spite  of  repeated  blistering,  the  stiff- 
ness still  persisted  in  the  back  of  his  neck.  Improvement  wrent 
on  fairly  rapidly  up  to  a  certain  point,  but  then  came  to  a 
standstill.  Forcible  manipulation,  however,  assisted  by  thor- 
ough kneading,  soon  effected  a  cure. 

In  this  case  the  mischief  was  well  defined,  the  ultimate  re- 
covery, though  it  was  delayed  for  some  time,  was  complete, 
and  there  was  no  inflammation  or  other  complication.  The 
cord  itself  was  not  injured,  though  just  at  first  there  was  rea- 
sonable ground  for  suspicion ;  the  whole  of  the  symptoms  were 
due  to  the  damage  the  muscles  and  ligaments  had  sustained, 
and  to  the  way  in  which  the  nerves  were  stretched. 


156  Sprains ;  their  Consequences  and  Treatment. 

In  all  probability,  as  Page  has  pointed  out,  many  of  the 
cases  of  what  is  sometimes  called  railway  spine  may  be  ac- 
counted for  in  this  way.  The  sjanptoms,  because  the}^  are 
serious  and  persistent,  are  referred  to  the  spinal  cord,  instead 
of  to  the  structures  which  surrounded  and  are  especially  in- 
tended to  protect  it. 

Paralysis  is  one  of  these.  Where  this  really  exists  there 
can  be  no  question  that  the  spinal  cord,  or  the  nerves  at  their 
exit  from  it,  have  sustained  some  exceedingly  grave  hurt.  It 
may  be  that  curious,  almost  indefinable,  effect  known,  for  want 
of  a  better  term,  as  shock  to  the  nervous  system ;  or  it  may 
be  actual  bruising  and  laceration ;  something  of  the  kind  there 
must  be,  and  in  such  a  case  it  is  necessary  to  exercise  the  most 
extreme  precaution  in  the  question  of  prognosis.  But  it  often 
happens  that,  without  the  least  intention  of  deceiving,  patients 
describe  themselves  as  paralyzed,  or  unable  to  perform  some 
particular  action,  when,  as  a  matter  of  fact,  the  attempt  is 
merely  prevented  by  pain,  or,  what  is  still  more  singular,  by 
the  belief  that  they  cannot.  Hood  has  pointed  out  how  pa- 
tients often  describe  a  joint  as  feeling  weak,  speaking  of  it  as  if 
it  were  in  need  of  some  mechanical  support,  when  the  real 
cause  is  the  dread  of  calling  into  action  muscles  that  are  stiff- 
ened from  disuse  or  rheumatism.  So  it  is  with  the  spine ;  after 
a  severe  strain  there  is  a  certain  amount  of  difficulty  about 
calling  the  muscles  into  play,  just  as  there  is  when  they  are 
affected  by  lumbago,  and  the  patient  is  naturally  very  apt  to 
think  that  he  has  lost  power  over  them,  and  is  going  to  be 
paralyzed.  This  was  the  case  in  the  instance  that  I  have 
quoted  above,  and  similar  examples  affecting  different  parts 
of  the  body,  according  to  the  seat  of  injury,  are  of  exceedingly 
common  occurrence. 

Hypersesthesia,  again,  or  increased  sensitiveness  of  the  skin, 
is  always  regarded  with  great  apprehension.  In  some  par- 
ticular cases,  as  I  have  mentioned  already,  it  is  true  that  it  is 
a  symptom  of  injury  to  the  spinal  cord ;  but  in  the  great  ma- 
jority, especially  in  those  in  which  it  extends  down  the  whole 
of  the  spinal  column,  it  occurs  for  exactly  the  same  reason 
that  it  does  over  any  sprained  ligament,  or  muscle,  and  means 
nothing  more. 

The  crawling  sensations,  too,  that  are  complained  of  in 
various  parts  of  the  body,  the  tingling,  and  pins  and  needles, 


Sprains ;  their  Consequences  and  Treatment.  157 

are  still  more  ambiguous.  Often  they  are  due  to  causes  of  an 
entirely  different  nature,  pressure  or  traction,  for  example,  on 
some  of  the  nerves,  or  some  alteration  in  the  amount  of  blood 
flowing  through  the  part;  they  cannot,  at  least  in  the  absence 
of  other  evidence,  be  regarded  as  proof  that  the  spinal  cord 
has  suffered  to  the  exclusion  of  everything  else.  Occasionally 
even  more  remarkable  symptoms  are  met  with.  In  one  case 
under  my  own  observation,  where  the  patient  sustained  a  very 
severe  strain  with  some  contusion  in  the  lower  part  of  the 
dorsal  region,  there  were  typical  attacks  of  what  are  known 
as  lightning  pains,  shooting  round  the  body  with  great  in- 
tensity, and  then  ceasing  abruptly;  yet  there  was  no  evidence 
at  any  time  that  the  injury  had  involved  the  spinal  cord  itself. 

In  short,  these  symptoms,  which  are  usually  regarded  as 
definite  proof  that  the  cord  has  been  injured,  so  far  as  they 
prove  anything,  are  rather  suggestive  of  injury  to  the  struct- 
ures that  lie  round  it  and  protect  it.  These  must  sustain  the 
brunt  of  the  violence  in  any  accident;  the  cord  itself  is  placed 
in  the  position  of  the  greatest  possible  security,  protected  as 
far  as  it  can  be  from  any  external  hurt,  so  that  in  the  vast 
majority  of  instances  it  (very  fortunately)  escapes.  From  its 
great  importance,  and  from  the  disastrous  results  when  it  is 
injured,  it  has  caused  everything  else  to  be  overlooked  and 
forgotten. 

Injury  to  the  Bones. — Of  the  frequency  with  which  the 
bones  are  affected  there  can  be  little  doubt.  Injuries  of  the 
back,  in  the  shape  of  blows  or  strains,  have  to  account  for  a 
very  large  proportion  of  cases  of  disease  of  the  spine;  and, 
probably,  if  the  history  of  the  rest  could  be  obtained,  it  would 
be  found  to  be  true  of  most  of  these.  It  is  difficult,  of  course, 
to  bring  forward  direct  proof  of  this;  but  a  certain  amount  of 
confirmation  may  be  obtained  from  the  locality  in  which  this 
affection  is  most  common.  A  blow  may  affect  any  part;  but 
strains,  in  such  a  structure  as  the  vertebral  column,  are  always 
felt  most  severely  where  a  rigid  and  a  flexible  segment  are 
joined  together — where,  for  example,  the  neck  or  the  lumbar 
region  joins  the  thorax,  which,  from  the  attachment  of  the  ribs 
and  for  other  reasons,  is  peculiarly  stiff.  At  any  rate,  whether 
this  is  the  explanation  or  not,  it  is  a  fact  that  disease  of  the 
spine  is  particularly  common  at  these  two  spots. 

Injury  to  the  Smaller  Joints. — Sometimes  the  strain  falls 


158  Sprains ;  their-  Consequences  and  Treatment. 

on  the  smaller  joints  between  the  vertebrae,  though  it  must  be 
admitted  that  it  is  rarely  possible  to  find  any  direct  evidence 
of  their  being  hurt.  There  are  so  many  of  them ;  they  lie  so 
close  to  each  other;  and  the  amount  of  movement  possessed 
by  each  is  so  slight  that  unless  the  injury  is  extremely  local- 
ized its  effect  is  spread  too  widely  to  strain  any  single  one. 
It  is  not  improbable,  however,  that  they  suffer  more  often  than 
is  generally  suspected;  only  the  injury,  owing  to  the  depth  at 
which  they  lie,  and  the  way  in  which  they  are  covered  in  by 
muscles,  is  not  correctly  diagnosed.  At  least,  evidence  of 
past  mischief  is  sometimes  found  post-mortem,  long  after  all 
histor3T  is  forgotten ;  and  suppuration  even  has  been  known  to 
occur,  and  to  spread  until  it  made  its  way  into  the  spinal  canal, 
and  involved  the  cord  itself. 

Ligaments. — The  structures,  however,  which  bear  the 
brunt  of  strains,  are  the  bands  of  fibrous  tissue,  and  the  mus- 
cles on  the  back  and  on  either  side  of  the  vertebral  column. 
With  regard  to  these,  the  part  played  by  the  former  is  entirely 
mechanical.  Close  under  the  surface  there  is  a  broad  sheet  of 
extraordinary  strength,  extending  outward  over  the  muscles, 
binding  them  down,  and  protecting  them  so  far  as  it  can  from 
being  overstretched.  A  little  deeper  it  is  much  more  delicate 
and  vascular,  forming  sheaths  for  all  the  separate  slips,  and 
uniting  them  closely  to  each  other.  Deeper  still  it  becomes 
strong  again ;  but  here  the  fibres  are  short  and  irregular  in 
direction,  running  between  the  prominences  with  which  the 
bones  are  covered,  and  acting  the  part  of  ligaments.  This 
fibrous  tissue  cannot  stretch.  When  the  violence  is  so  great 
that  the  muscles  are  overcome,  or  so  sudden  that  they  are 
caught  unawares,  it  resists  as  long  as  it  can ;  then  it  gives 
way,  rarely  at  any  one  single  spot;  more  often  here  and  there, 
where  it  is  attached  to  the  bones,  or  becomes  continuous  with 
the  muscles. 

Muscles. — These,  on  the  other  hand,  are  the  most  active 
ligaments  the  back  possesses.  Not  only  do  they  move  one 
bone  upon  another,  but,  within  certain  limits,  they  are  the 
main  agents  by  which  the  extent  of  the  movement  is  regulated. 
When  those  limits  are  passed,  and,  as  a  rule,  not  till  then,  the 
purely  passive  fibrous  bands  are  called  into  play. 

The  result  of  this  is  that,  as  a  rule,  in  accidents  of  this  kind, 
the  muscles  suffer  to  a  very  serious  extent.  Sometimes  they 


Sprains ;  their  Consequences  and  Treatment.  159 

are  overstretched,  and  lose  their  power  of  contracting  again ; 
or  they  are  seized  with  cramp;  or  they  are  crushed  together 
and  bruised.  Sometimes  there  is  a  great  effusion  of  blood  into 
their  substance,  so  that  they  become  swollen  and  painful;  or 
the  sheath  of  fascia  which  surrounds  them  is  split  open  to  such 
a  degree  that  they  are  displaced  entirely  from  their  surround- 
ings, and  dislocated ;  or  they  are  even  torn  in  two  or  wrenched 
from  their  attachments. 

Dislocation  of  Muscles. — Many  of  these  injuries  occur 
commonly  in  sprains  of  other  joints,  but  one  of  them,  disloca- 
tion, is,  if  not  confined  to  the  back,  at  least  very  rarely  met 
with  elsewhere.  It  is  most  common  in  the  neck,  for  here  the 
movements  are  very  rapid  and  extensive,  while  the  muscles 
are  especially  long  and  slender.  The  head  is  suddenly  twisted 
round  to  look  in  some  awkward  direction;  there  is  a  sudden 
sharp  stab  of  pain,  often  causing  the  patient  to  cry  out ;  some- 
thing appears  to  be  caught,  and  the  head  is  held  fixed.  In  a 
minute  or  two,  when  the  acute  pain  has  subsided,  it  can  gen- 
erally be  brought  nearly  straight  again;  but  it  requires  con- 
siderable effort,  and  it  cannot  be  turned  so  as  to  face  in  the 
opposite  direction,  or  even  kept  straight  for  long.  As  soon  as 
it  is  allowed  to  assume  the  position  of  least  discomfort,  it  bends 
over  once  more  to  the  affected  side.  Careful  examination  in 
these  cases  sometimes  shows  a  tender  spot  on  the  contracted 
side,  slightly  too  prominent.  If  this  corresponds  in  position 
and  direction  to  some  muscular  slips,  and  if,  when  the  part  is 
manipulated,  the  swelling  disappears,  and  full  and  painless 
mobility  is  instantaneously  restored,  it  can  hardly  be  doubted 
that  the  symptoms  were  due  to  the  dislocation  of  one  of  these, 
which  has  slipped  back  into  its  place  again.  In  some  cases  an 
audible  snap  can  be  heard  by  the  patient  at  the  moment  of 
reduction;  and,  in  one  under  my  own  care,  an  incautious  move- 
ment on  the  part  of  the  patient,  before  repair  was  complete, 
reproduced  the  displacement. 

I  have  known  several  instances  in  which,  from  the  prac- 
tically instantaneous  character  of  the  relief,  it  is  almost  certain 
that  this  had  happened;  but  I  must  admit  it  is  much  more 
common  for  the  swelling  to  disappear  gradually  and  for  vol- 
untary power  to  return  by  slow  degrees.  Probably,  in  these 
instances,  there  is  no  real  dislocation ;  the  muscular  fibres  are 
either  in  a  state  of  painful  and  spasmodic  contraction,  such  as  is 


160  Sprains ;  their  Consequences  and  Treatment. 

common  in  the  leg  after  unusual  exertion,  or  some  of  them  have 
been  torn  and  strained,  so  that  movement  is  painful  until  the 
injury  is  repaired,  and  the  extra vasated  blood  absorbed  again. 

I  have  never  met  with  any  similar  unmistakable  disloca- 
tion in  the  loins,  though,  no  doubt,  from  the  description  given 
by  Callender,  its  occurrence  is  quite  possible.  The  patient,  he 
narrates,  was  carrying  a  heavy  weight  on  his  shoulders,  when 
he  suddenly  slipped,  and,  in  spite  of  all  he  could  do,  was  swung 
round  by  the  momentum.  The  pain  for  the  moment  was  in- 
tense, and  though  it  did  not  continue  his  back  remained  stiff, 
so  that  he  could  not  move  about  with  proper  freedom.  On 
examining  the  part  there  was  one  very  tender  spot  in  the 
muscles  by  the  side  of  the  spine,  where  a  decided  irregularity 
could  be  detected;  this  was  diagnosed  as  a  dislocation.  The 
patient  was  instructed  to  repeat,  so  far  as  he  could,  the  move- 
ments he  went  through  as  he  fell;  and  while  doing  this  firm 
pressure  was  made  on  the  painful  spot.  The  swelling  disap- 
peared at  once;  full  power  of  movement  was  regained;  and  the 
sensation  of  stiffness  completely  vanished.  The  case  was  com- 
pleted, and  the  diagnosis  verified  by  a  subsequent  repetition 
of  the  accident. 

Method  of  Reduction. — In  any  injury  of  this  description, 
even  if  the  presence  of  a  dislocation  is  not  certain,  it  is  always 
worth  while  to  carry  out  some  simple  manipulation  such  as 
that  described  above.  Whatever  may  be  the  reason,  whether 
it  relaxes  spasm,  or  whatever  it  does,  it  is  a  fact  that  almost 
immediate  relief  is  sometimes  gained  by  this,  though  the  symp- 
toms are  not  in  the  least  characteristic.  In  one  case  under  my 
own  care  there  was  no  history  of  an  accident  at  all.  The  pa- 
tient was  a  young  man,  healthy  enough  himself,  but  of  rheu- 
matic and  gouty  parentage.  He  had  been  sitting  incautiously 
in  a  draught  when  overheated,  and  got  an  attack  of  muscular 
rheumatism.  Curiously  enough,  however,  the  pain  was  limited 
to  one  side,  and  almost  to  one  spot;  had  he  met  with  an  acci- 
dent, I  should  at  once  have  suspected  the  existence  of  a  strain. 
In  spite  of  the  history,  however,  I  determined  to  try  the  effect 
of  sudden  vigorous  contraction,  and  accordingly  made  him  sit 
down  on  a  low  seat,  with  his  feet  firmly  pressed  against  the 
wall  in  front,  so  that  the  pelvis  should  be  securely  fixed.  The 
tender  spot  was  carefully  marked,  and  then  it  was  explained 
to  him  that  he  must  stoop  forward  as  low  as  possible,  and  at 


Sprains;  their  Consequences  and  Treatment.  161 

the  word  of  command  suddenly  straighten  himself  up.  One 
arm  was  placed  under  his  chest  to  assist  him  in  this,  and  the 
thumb  of  the  other  hand  firmly  pressed  upon  the  tender  spot. 
The  patient  carried  his  part  out  loyally,  in  spite  of  the  pain, 
and  was  completely  and  thoroughly  cured  at  the  second  at- 
tempt. Some  pain  and  stiffness  returned  in  the  course  of  the 
next  day,  but  determined  extension  and  contraction  of  the 
muscles  involved,  relieved  him  without  further  assistance. 

It  is  very  important  in  accidents  of  this  kind  to  get  a  per- 
fectly accurate  account  of  the  way  in  which  it  happened,  and 
the  smallest  details  often  prove  of  great  importance.  The 
chief  difficulty  is  to  determine  whether  the  seat  of  injury  is  one 
of  the  smaller  joints,  or  a  muscular  slip  by  the  side  of  it. 
Sometimes  a  soft  and  rather  indefinite  swelling  can  be  made 
out  beneath  the  skin;  more  often  there  is  merely  a  certain 
amount  of  local  tenderness,  with  a  sensation  of  stiffness,  or  of 
inability  to  execute  some  particular  movement,  amounting  in 
some  cases,  as  has  been  already  mentioned,  even  to  a  suspicion 
of  paralysis  in  the  patient's  mind.  Bruising  is  rarely  seen, 
owing  to  the  depth  at  which  the  injured  part  lies. 

If  the  situation  corresponds  fairly  well  with  the  position 
and  direction  of  some  slender  slip  of  muscle,  the  assistance  of 
the  patient  must  be  called  in,  and  what  is  required  of  him 
thoroughly  explained.  There  are  two  chief  ways  in  which  the 
reduction  may  be  effected;  sometimes  one  succeeds,  sometimes 
the  other.  In  the  first  the  patient  is  placed  in  an  attitude 
that  relaxes  the  injured  part  as  much  as  possible,  and  then, 
while  the  hand  or  finger  is  firmly  pressed  upon  it,  is  made  to 
bring  it  suddenly  and  vigorously  into  action.  In  the  second, 
which  is  rather  the  better — for  it  is  very  difficult  at  once,  and 
when  suffering  pain,  to  move  the  back  or  neck  quickly  in  any 
given  direction  at  a  moment's  notice — the  body  is  placed  so  that 
the  dislocated  slip  is  put  upon  the  stretch,  and  held  in  that  po- 
sition by  the  operator,  while  the  patient  endeavors  to  straighten 
himself  up  against  the  resistance.  The  muscle  suddenly  con- 
tracts, alters  its  shape  and  consistence,  and,  from  the  relief  that 
is  experienced  afterward,  must,  apparently,  slip  back  again 
into  its  bed.  Sometimes  there  is  a  sharp  feeling  of  pain  at  the 
moment,  and  the  preliminary  stretching  is  always  disagree- 
able, but  the  use  of  an  anaesthetic  is,  of  course,  impossible. 

Muscular  Pain. — The  most  common  trouble,  however,  after 


1 62  Sprains ;  their  Consequences  and  Treatment. 

sprains  is  something-  different  to  this,  and  is  probably  closely 
allied  to  muscular  rheumatism.  It  may  be  the  result  of  un- 
usually severe,  or  of  unusually  prolonged  effort;  nothing-  is 
felt  at  the  time,  or  for  a  few  hours;  then,  g-enerally  speaking, 
at  night  a  peculiar  aching  sensation  begins  to  make  itself  felt. 
The  skin  is  often  tender  to  the  touch,  especially  over  the  points 
that  correspond  to  the  exit  through  the  fascia  of  the  cutaneous 
nerves ;  but  there  is  no  heat  or  redness.  The  tissues  show  no 
sign  of  bruising ;  steady  pressure,  though  it  is  unpleasant  at 
first,  gives  relief  rather  than  causes  pain ;  and,  except  as  a  re- 
sult of  disturbed  rest  and  sleep,  there  is  no  fever  or  constitu- 
tional disturbance.  There  is  merely  a  constant  wearing  pain, 
with  a  sensation  of  stiffness  and  want  of  power,  that  renders 
rest  for  any  length  of  time  impossible,  and  entirely  prevents 
the  patient  holding  himself  upright  or  moving  about  with 
freedom. 

What  may  be  the  actual  nature  of  the  change  in  the  tissues 
is  uncertain  in  many  of  these  cases.  In  some,  no  doubt,  there 
is  rupture,  or  straining  of  the  muscular  fibres,  or  there  are 
minute  haemorrhages;  but  from  the  practical  identity  of  the 
symptoms  with  those  of  myalgia,  due  to  cold  or  gout,  it  seems 
probable  that  the  cause  is  to  be  sought  in  the  changed  condi- 
tion of  the  circulation,  or  of  the  nutrition  of  the  part.  During 
contraction  of  the  muscles  a  much  larger  amount  of  blood 
flows  through  them  than  when  they  are  at  rest,  and  the  blood- 
vessels are  very  much  dilated.  It  is  possible  that  when  this  is 
carried  to  excess  by  prolonged  overwork  it  is  succeeded  by  a 
condition  of  passive  congestion,  the  vessels  being  overloaded, 
and  the  blood  unable  to  circulate  as  freely  or  as  rapidly  as  it 
should.  Then  the  waste  products  accumulate  and  act  as 
sources  of  irritation,  and  fresh  material  to  replace  that  which 
is  exhausted  by  fatigue  is  not  supplied  in  sufficient  quantity. 
Probably  in  those  who  are  young  and  healthy  this  is  not  of 
material  consequence;  it  merely  causes  a  certain  amount  of 
muscular  stiffness,  which  soon  subsides  when  the  part  is  rested 
and  the  natural  equilibrium  once  more  restored;  but  if  any 
constitutional  taint,  such  as  gout  or  rheumatism,  is  present 
too,  it  seems  to  stamp  the  complaint  with  its  own  peculiar 
character,  and  makes  it  tenfold  more  severe. 

The  most  common  situation  for  this  to  occur  is  in  the  loins, 
owing  to  the  large  masses  of  muscle  situated  there,  and  to  the 


Sprains;  their  Consequences  and  Treatment.  163 

way  in  which  they  are  called  upon  for  unusual  or  sudden  ex- 
ertion m  lifting1  heavy  weights;  but  it  may  occur  anywhere, 
even  in  the  extremities.  Wherever  it  is,  care  must  be  taken 
not  to  confound  it  with  other  disorders.  It  is  not  uncommon 
for  affections,  even  of  such  distant  parts  as  the  viscera,  to  be 
attended  by  pain  in  various  regions  of  the  spine.  To  say  noth- 
ing of  examples  which  must  occur  to  every  one,  I  have  known 
the  back-pain  of  incipient  small-pox  treated  as  lumbago,  and 
massage  has  before  now  been  vigorously  applied  to  a  case  of 
stone  in  the  kidney. 

General  Treatment. — In  the  milder  cases  merely  local 
treatment  may  suffice,  but  it  is  so  common  for  an  outbreak  of 
some  complaint  (the  existence  of  which  may  hitherto  not  have 
been  suspected)  to  follow  strains,  that  practically  in  all  general 
treatment  adapted  to  the  particular  constitution  of  each 
patient  is  essential.  Just  as  an  injury  to  the  foot  is  often  the 
apparent  cause  of  the  first  attack  of  gout,  so  many  of  the 
muscular  strains  of  the  back  owe  at  any  rate  their  persistent 
character  to  the  presence  of  some  similar  complication.  It  is 
for  this  reason  that  careful  attention  to  diet  is  so  necessary ; 
and  that  such  drugs  as  colchicum,  iodide  of  potash,  chloride 
of  ammonia,  the  carbonates  of  the  alkalies,  and  others  prove 
so  useful.  Only  it  rarely  happens  that  any  indication  as  to 
which  of  these  internal  remedies  is  likely  to  prove  most  bene- 
ficial can  be  derived  from  the  condition  of  the  back  itself. 
This  is  only  to  be  ascertained  by  carefully  inquiring  into  the 
previous  history  of  the  patient,  and  thoroughly  investigating 
the  other  symptoms  that  are  present.  In  other  words,  local 
measures  should  be  employed  to  relieve  the  pain  and  stiffness, 
and  to  restore  the  condition  of  the  muscles  as  soon  as  possible; 
but  it  must  not  be  forgotten  that  the  general  state  of  the  pa- 
tient in  most  instances  needs  quite  as  much  attention. 

Local  Measures.  Warmth. — Warmth,  either  applied  to 
the  part  itself,  or  generally  over  the  whole  surface  of  the  body, 
is  of  excellent  service  in  relieving  the  consequences  of  strains. 
The  simplest  plan  is  to  wring  a  piece  of  flannel  out  of  water  as 
hot  as  can  be  borne,  or  to  roast  it  in  front  of  a  fire,  and  press 
it  firmly  upon  the  affected  area,  renewing  it  from  time  to  time 
as  it  cools.  The  skin  becomes  red;  more  blood  circulates 
through  it,  and  probably  a  considerable  amount  is  diverted 
from  the  deeper  parts;  the  congestion  is  relieved  for  the  time 


164  Sprains ;  their  Consequences  and  Treatment. 

being-;  the  waste  products  are  carried  away;  more  nutritive 
material  is  supplied,  and  the  stiffness  certainly  diminishes.  Or 
bags  of  hot  sand,  or  salt,  may  be  used ;  they  retain  the  heat 
considerably  longer,  and  from  the  way  in  which  they  can  be 
fitted  into  any  irregularity  of  surface,  are  particularly  suited 
to  certain  parts  of  the  body.  If  this  is  not  convenient,  the 
electric  brush  may  be  tried,  passing-  it  regularly  all  over  the 
surface  of  the  skin  after  it  has  been  thoroughly  dried  first  to 
increase  the  resistance.  It  is  probable  that  the  benefit  derived 
from  this  is  due  almost  entirely  to  the  influence  it  possesses 
on  the  blood-vessels,  and  not  in  any  way  to  the  chemical  effects 
of  the  current. 

Baths. — Hot-water  or  vapor  baths  are  almost  too  well 
known  to  require  mention.  Turkish  ones  also  enjoy  a  great 
reputation,  especially  for  recent  cases,  and  among  those  who 
are  accustomed  to  them.  For  others,  they  must  be  recom- 
mended with  a  certain  amount  of  caution,  and  the  subsequent 
treatment  in  any  case  requires  much  more  attention  than  it 
usually  receives.  At  Aix,  when  the  full  effect  is  desired,  the 
patient,  after  his  bath,  is  quickly  dried,  wrapped  in  blankets, 
and  carried  in  a  sedan  chair  to  his  hotel.  As  soon  as  he  reaches 
his  apartment  he  is  lifted  into  bed,  still  swathed  like  a  mummy, 
covered  up  with  additional  blankets  and  a  quilt,  and  left  to 
perspire  for  a  longer  or  shorter  period.  After  twenty  minutes 
or  half  an  hour  he  is  carefully  rubbed  down  by  an  attendant 
who  had  accompanied  him  from  the  bath.  Where  this  is  im- 
practicable, the  patient  should  at  least  be  very  careful  not  to 
hurry  away,  but  to  remain  two  or  three  hours  if  necessary,  and 
above  all,  to  make  sure  that  he  is  properly  covered  up. 

When  the  complaint  has  already  lasted  some  time,  douche 
baths  may  be  employed,  conjointly  with  vapor  baths.  The 
patient  should  be  seated  on  a  wooden  stool,  with  the  feet  im- 
mersed in  warm  water  so  as  to  avoid  chill,  and  then  jets  may 
be  directed  against  his  back  in  any  required  direction.  The 
size  of  the  jet  must  be  regulated  by  the  amount  of  pressure, 
and  by  the  temperature  of  the  water;  but  it  is  rarely  advisable 
for  it  to  be  more  than  a  quarter  of  an  inch  in  diameter,  and  it 
is  always  best  to  begin  with  warm  water,  and  gradually  re- 
place it  by  cold.  The  effect  is  greatly  enhanced  by  massage 
afterward. 

Those  wrho  have  never  tried  these  baths,  or  who  suffer 


Sprains ;  their  Consequences  and  Treatment.  165 

either  from  giddiness  and  a  feeling1  of  fullness  in  the  head,  or 
from  a  sensation  of  faintness  after  their  use,  may  be  recom- 
mended to  take  local  ones  with  perfect  safetj'.  If  the  patient 
is  in  bed,  a  cradle  may  be  placed  over  the  body  so  as  to  leave 
a  space  round  him,  beneath  the  bedclothes,  and  the  steam  of 
a  kettle  introduced  by  means  of  properly-arranged  tubing, 
until  the  desired  effect  is  produced,  taking  care  not  to  scald 
the  patient's  legs.  Where  he  can  sit  on  a  chair,  it  is  more 
convenient  to  arrange  a  mackintosh,  or,  if  this  is  not  available, 
a  blanket,  round  his  neck,  so  as  to  reach  the  floor  on  all  sides, 
and  then  to  place  under  the  seat  of  a  chair  a  spirit  lamp  with 
some  boiling  water.  Both  these  methods  insure  copious  per- 
spiration within  a  very  few  minutes,  and  possess  the  great 
advantage  of  not  affecting  the  patient's  head  or  interfering 
with  his  respiration.  Further,  there  is  less  risk  of  catching 
cold  afterward,  and  aggravating  or  reproducing  the  original 
trouble ;  if  the  bath  is  taken  of  an  evening,  the  patient  can  be 
placed  in  bed  at  once,  and  nearly  always  can  make  sure  of 
some  hours'  refreshing  sleep. 

At  Aix-les-Bains,  according  to  Dr.  Stewart,  the  method  is 
still  more  highly  elaborated.  When  the  patient  is  sent  to 
have  a  steam  bath  (the  Berthollet,  as  it  is  termed),  he  is 
directed  to  an  apartment  which  contains  a  curious  wooden 
box,  with  a  round  hole  in  the  movable  lid.  After  undressing, 
he  steps  into  the  box^  and  finds  that  he  is  shut  in  all  but  the 
head,  the  round  hole  being  occupied  by  his  neck.  Immediately 
a  valve  on  the  level  of  the  floor  is  opened,  the  hot  vapor  rises 
about  him,  and  he  soon  begins  to  perspire  freely.  The  per- 
spiration running  down  his  brow  trickles  from  his  face.  Pres- 
ently he  feels  the  streams  flow  down  his  sides  and  legs,  and 
very  speedily  a  feeling  of  oppression  and  debility  comes  on. 
After  ten  or  twenty  minutes  the  bath  is  opened  up,  the  patient 
carefully  dried,  and  removed  to  his  hotel. 

Hot-water  baths  act  in  the  same  way.  The  beneficial  effect 
they  exercise  is  almost  entirely  due  to  their  temperature,  and 
proportionate,  within  limits,  to  the  length  of  application. 
The  salts  that  they  contain,  whether  neutral,  alkaline,  or  sul- 
phuretted, are  of  very  little  consequence.  If  they  exist  in  cer- 
tain degrees  of  concentration,  they  stimulate  the  cutaneous 
circulation,  but  that  is  all.  For  this  reason  peat  or  mud  baths 
are,  as  a  rule,  more  efficacious.  The  one  feature  common  to 


1 66  Sprains ;   their  Consequences  and  Treatment. 

all  bathing-  establishments  which  enjoy  a  high  repute  is  the 
temperature  of  the  water,  and  probably  the  benefit  derived 
from  the  use  of  the  baths  (as  distinguished  from  a  sojourn  at 
the  place)  is  due  entirely  to  this. 

Friction, — Friction,  either  with  the  hand  or  with  a  flesh 
brush,  is  very  grateful  in  these  cases.  The  direction  should  be 
upward,  toward  the  head,  and  the  strokes  light  and  rapid. 
The  effect  is,  to  a  certain  extent,  the  same  as  that  of  heat ; 
there  is  a  temporary  contraction  of  the  vessels  near  the  sur- 
face, followed  by  a  more  lasting  dilatation  and  more  rapid  circu- 
lation of  the  blood.  It  possesses,  however,  in  addition,  con- 
siderable influence  on  the  nerves  of  sensation,  and  it  is  not 
improbable  that  it  is  felt  even  more  widely  than  this  would 
imply.  At  least,  it  is  difficult  to  explain  on  other  grounds  the 
undoubted  power  which  steady  friction  along  the  back  seems 
to  possess  in  allaying  some  forms  of  nervous  excitement  and 
inducing  sleep. 

Liniments. — Stimulating  liniments,  containing  camphor, 
ammonia,  or  turpentine,  may  be  usefully  employed  in  conjunc- 
tion with  either  friction  or  heat.  Sprinkling  a  few  drops  of 
turpentine  on  the  heated  flannel  before  applying  it  is  gener- 
ally sufficient,  or  some  of  the  liniment  may  be  rubbed  in  with 
the  hand.  This  acts  as  a  mild  form  of  counter-irritant,  prob- 
ably temporarily  withdrawing  the  blood  from  the  deeper  parts 
toward  the  surface,  and  where  the  stiffness  and  pain  have 
lasted  some  time  this  is  more  effectual  than  either  heat  or  fric- 
tion by  itself.  If  the  tenderness  is  limited  to  one  or  two  spots, 
and  especially  if  these  correspond  to  the  places  where  the 
nerves  perforate  the  fascia,  blistering  fluid,  painted  on  once  or 
twice,  according  to  the  thickness  of  the  skin,  answers  better 
still. 

In  rare  and  exceptional  cases  more  powerful  applications, 
even  the  actual  cautery,  may  be  used.  How  these  act  is  not 
clear;  they  may  merely  withdraw  blood  from  the  deeper  parts 
or  they  may  act  in  some  way  through  the  nervous  system; 
for  there  is  little  doubt  that  certain  organs  are  always  in 
definite  nervous  relation  with  certain  parts  of  the  surface  of 
the  body,  and  are  affected  when  these  are  in  any  way  stimu- 
lated. However  this  may  be,  there  is  no  question  that  some- 
times this  agent  may  be  employed  in  relieving  deep-seated 
pain,  especially  about  the  bones,  with  conspicuous  success. 


Sprains ;   their  Consequences  and  Treatment.  167 

When  the  skin  feels  sore  and  tender  after  a  sprain,  the 
essential  or  aromatic  oils  often  give  very  great  relief.  Many 
of  the  quack  remedies  employed  to  soothe  pain,  even  the  deep- 
seated  pain  of  acute  gout,  owe  what  merit  they  possess  almost 
entirely  to  these.  A  very  favorite  application  in  Germany, 
known  as  Hoffmann's  balsam  of  life,  consists  of  an  alcoholic 
solution  of  balsam  of  Peru  and  seven  of  these  aromatic  oils 
mingled  together.  They  may  be  either  painted  on  the  skin, 
and  left  exposed,  or  dissolved  in  spirit  in  various  proportions, 
and  covered  over  with  oiled  silk  to  prevent  too  rapid  evapora- 
tion. Menthol  is  one  of  the  most  convenient,  and  acts  especi- 
ally well  when  mixed  wTith  camphor  or  croton-chloral,  so  as 
to  form  a  thick  oily  liquid.  Probably  in  this  instance,  too,  the 
relief  is  in  no  small  measure  due  to  the  effect  produced  upon 
the  cutaneous  nerves. 

In  certain  cases  minute  quantities  of  morphia,  belladonna, 
or  veratria  may  be  combined  with  these.  It  must,  however, 
be  remembered  that  if  chloroform  is  used  as  a  solvent,  a  con- 
siderable amount  is  absorbed  through  the  skin,  particularly 
if  friction  is  used  at  the  same  time,  and  that  in  spite  of  the 
comparative  thickness  of  the  cutaneous  covering  of  the  back 
and  the  paucity  of  sebaceous  glands.  Belladonna  plasters, 
which  are  strongly  recommended  by  some,  not  only  share 
with  all  other  plasters  the  objection  of  being  intolerably  dirty, 
but  have  the  additional  disadvantage  of  sometimes  causing 
an  acute  attack  of  eczema.  Quite  as  great  benefit  may  be 
derived  by  wearing  a  belt  of  flannel  or,  if  this  is  too  irritat- 
ing, one  of  silk  next  the  skin. 

The  hypodermic  injection  of  anodynes,  such  as  morphia, 
may  occasionally  be  necessary,  but  it  is  always  as  well  to 
postpone  this  until  all  other  remedies  have  been  exhausted. 
The  very  ease  with  which  it  gets  rid  of  the  pain  is  its  greatest 
danger.  It  rarely  cures  the  complaint,  though  it  gives  a  tem- 
porary sensation  of  comfort,  and  is  only  too  likely  to  be  re- 
quired again  before  many  hours  are  past. 

Ironing. — Besides  these  there  are  other  remedies  which  are 
especially  suited  to  deep-seated  and  large  muscular  masses, 
such  as  exist  on  either  side  of  the  spine  in  the  loins.  Ironing 
has  already  been  alluded  to.  The  patient  should  lie  in  bed, 
rather  on  his  face,  with  the  body  supported  by  pillows  in  as 
comfortable  a  position  as  possible,  and  should  turn  from  side 


1 68  Sprains ;  their  Consequences  and  Treatment. 

to  side  as  occasion  requires.  A  well-warmed  piece  of  flannel 
(great  stress  is  laid  by  some  on  its  being-  unwashed)  is  then 
stretched  over  the  affected  part,  and  the  muscles  on  either 
side  of  the  backbone  thoroughly  ironed  in  all  directions  with 
an  iron  as  hot  as  can  conveniently  be  borne,  using  consider- 
able pressure  at  the  same  time.  The  best  for  this  purpose  are 
those  of  rather  small  size,  with  the  edges  and  angles  well 
rounded  off,  so  that  they  may  be  pressed  into  all  the  depres- 
sions between  the  bones  without  causing  pain. 

Acupuncture. — Acupuncture,  ag-ain,  though  it  is  rarely  em- 
ployed nowadays,  and  seems,  like  bleeding-,  to  have  gone  out 
of  fashion,  is  at  times  very  efficient  in  removing  chronic  muscu- 
lar pain.  How  it  acts  is  not  thoroughly  explained.  Ordinary 
long-  darning  needles  answer  very  well.  They  are  simply 
thrust  through  the  skin,  deep  into  the  muscles,  and  withdrawn 
again  after  a  few  minutes.  If  the  plan  is  successful  they  leave 
behind  a  bright  red  areola,  which  varies  considerably  in  size 
and  duration  in  different  cases,  and  probably  is  dependent  on 
the  condition  of  the  nerves  that  are  stimulated.  The  pain  is 
exceedingly  slight,  especially  if  the  thrusts  are  made  firmly 
and  rapidly,  and  the  punctures  scarcely  bleed. 

Galvanism. — Galvanism,  too,  is  very  successful  in  treating- 
muscular  stiffness.  The  skin  should  be  well  sponged  over  first 
with  warm  salt  and  water,  so  as  to  avoid  irritation  as  much  as 
possible,  and  either  the  labile  or  the  stabile  plan  adopted.  The 
latter  is  the  best  to  commence  with,  and  then,  after  the  cur- 
rent has  been  passing  some  time,  the  direction  may  be  reversed 
once  or  twice.  The  electrode  applied  over  the  muscle  should 
be  of  larg-e  size  (a  zinc  plate  covered  over  with  leather,  well 
moistened,  answers  as  well  as  anything-,  as  it  may  be  cut  or 
bent  to  any  shape),  and  the  current  used  of  proportionate 
strength.  Then,  before  leaving-  off,  a  smaller  electrode  may 
be  substituted,  and  passed  over  the  whole  of  the  surface  with 
a  weaker  current  (if  possible  in  an  ascending'  direction)  so  as 
to  secure  its  refreshing  action  and  remove  any  sensation  of 
fatigue.  The  sittings  should  not  last  long-er  than  five  or  ten 
minutes,  and  it  will  generally  be  found  that  every  other  day 
is  sufficient,  especially  if  kneading-  or  ironing-  is  used  on  the 
alternate  ones. 

Massage. — Massage,  if  it  is  thoroughly  carried  out,  is  more 
successful  still.  Its  action  is  most  refreshing  and  invigorating. 


Sprains ;  their  Consequences  and  Treatment.  169 

Under  its  influence  the  aching-  and  stiffness  disappear,  the 
blood  circulates  more  freely  through  the  muscles,  the  waste 
products  are  carried  away,  nutrition  improves,  and  strength 
and  voluntary  power  beg-in  to  return  at  once.  It  seems  to 
possess  the  same  restorative  influence  over  the  deeper  struct- 
ures that  friction  has  upon  the  skin. 

Percussion  and  kneading  are  both  recommended.  The  for- 
mer is  the  easier,  and  does  not  require  so  much  skill  or  ex- 
perience ;  but  it  only  affects  superficial  parts,  and  is  altogether 
of  more  limited  application.  The  ulnar  side  of  the  hand  may 
be  used,  or  an  instrument  which  bears  a  general  resemblance 
to  a  hammer,  with  a  stem  of  whalebone  to  secure  elasticity, 
and  a  head  faced  with  India-rubber.  With  this,  held  rather 
lightly,  the  whole  of  the  stiff  and  painful  part  of  the  back  is 
thoroughly  percussed,  the  number  of  strokes  rising  to  as  many 
as  three  or  four  hundred  in  the  minute,  until  the  skin  begins 
to  glow. 

Kneading  is  of  much  greater  service,  but  requires  practice 
before  the  full  benefit  can  be  obtained.  The  object  is  to  com- 
press and  relax  alternately  the  deeper-lying  muscles,  and  to 
squeeze  their  contents  onward,  so  as  to  insure  a  more  rapid 
flow  of  blood  and  plasma  through  their  substance.  Conse- 
quently the  movement  must  be  regular,  definite  in  direction, 
and  well  ordered. 

A  muscle  at  rest  receives  an  exceedingly  small  quantity 
of  blood,  compared  to  what  flows  through  it  when  it  is  con- 
tracting. So  long  as  it  is  doing  no  work,  the  plasma  which 
pours  through  the  walls  of  the  vessels  into  the  interspaces 
round  remains  almost  stagnant;  the  fibres  are  very  slow  in 
getting  rid  of  their  waste  and  in  receiving  a  fresh  supply.  As 
soon  as  the  muscle  begins  to  act,  the  vessels  dilate,  the  current 
of  blood  is  quickened,  the  plasma  is  driven  on  at  a  much  faster 
rate,  and  the  nutrition  improves  beyond  all  measure  This  is 
helped  to  no  slight  extent  by  the  alteration  in  the  shape  of  the 
muscles.  These  are  all  incased  in  a  comparatively  unyielding 
fibrous  sheath,  differing  in  strength  and  density  in  different 
places.  The  plasma  collects  underneath  this,  filling  up  all  the 
clefts  and  spaces  left  between  the  fibres.  Each  time  the  muscle 
contracts  it  compresses  some  of  these,  and  causes  others  to 
dilate,  so  that  it  alternately  sucks  and  drives  the  fluid  plasma 
on.  And,  as  a  matter  of  fact,  it  is  well  known  that  the  flow 


170  Sprains ;   their  Consequences  and  Treatment. 

of  plasma,  as  well  as  that  of  blood,  through  the  substance  of  a 
muscle,  increases  immensely  as  soon  as  it  begins  to  work. 

Massage  aims  at  imitating  this.  Its  object  is,  by  the  roll- 
ing and  kneading  of  the  muscles,  to  increase  the  flow  of  blood 
and  plasma  through  them,  get  rid  of  the  accumulated  waste, 
and  stimulate  nutrition  by  supplying  fresh  material  in  larger 
quantity.  If  carried  out  thoroughly  it  is  almost  certain  to 
give  relief,  but  it  is  not  a  thing  to  be  undertaken  rashly,  with- 
out previous  training,  and  without  some  knowledge  of  anatomy. 
Massage  and  rubbing  are  not  synonymous  terms. 

Supposing  the  lumbar  region  to  be  affected,  the  patient 
must  be  placed  upon  a  couch  of  convenient  height — as  already 
described  in  speaking  of  ironing — and  well  supported  from  un- 
derneath by  cushions,  so  that  the  muscles  of  the  loin  may 
stand  out  beneath  the  skin  without  being  contracted.  The 
operator  should  stand  over  him,  at  a  suitable  distance,  so  that 
his  movements  are  not  cramped;  and  then,  with  both  hands, 
moving  one  after  the  other,  knead  and  squeeze  the  muscles, 
first  on  one  side  and  then  on  the  other,  rolling  them,  as  it 
were,  away  from  the  middle  line,  and  pressing  them  onward 
and  upward  toward  the  head.  The  whole  hand  must  be  used, 
the  fingers,  as  it  were,  being  insinuated,  as  far  as  possible, 
under  and  between  the  groups  of  muscle,  the  skin  being  allowed 
to  glide,  to  a  certain  extent,  over  the  structures  beneath.  Then, 
if  there  is  any  very  painful  spot  left,  the  muscles  may  be 
grasped  with  the  hands  and  firmly  kneaded  with  the  thumbs, 
moving  them  round  and  round  in  small  circles  intersecting 
each  other  over  it  so  as  to  knead  and  squeeze  the  structures 
round  it  from  all  sides. 

The  pressure  should  be  gentle  at  first,  and  then  gradually 
become  firmer  and  firmer.  No  liniment  or  oily  substance  can 
be  used,  as  it  weakens  the  grasp  of  the  hands  and  tends  to 
defeat  the  object  of  the  manipulation.  If  it  is  desired  it  may 
be  rubbed  in  afterward.  The  rate  of  movement  must  vary 
with  the  thickness  and  depth  of  the  tissues  to  be  manipulated, 
and  with  the  amount  of  pressure  used.  Within  reasonable 
limits,  the  slower  the  better.  There  is  a  great  tendency  on 
the  part  of  many,  who  are  supposed  to  practice  massage,  to 
use  much  too  much  force,  and  to  make  all  the  movements  too 
rapid.  Five  minutes,  as  a  rule,  is  sufficient  for  a  sitting, 
though  it  is  often  beneficial  to  apply  an  ascending  constant 


Sprains ;  their  Consequences  and  Treatment.  171 

current  to  the  muscles  for  a  minute  or  two  more  afterward. 
It  answers  better  to  repeat  the  manipulation  later  on  in  the 
day  than  to  continue  too  long  at  one  time.  The  golden  rule  is 
never  to  fatigue  the  patient,  or  to  produce  the  least  degree  of 
tenderness  or  bruising.  Those  who  have  not  had  much  ex- 
perience or  a  thorough  training  are  very  apt  to  overdo  it. 


CHAPTER  XIII. 

INTERNAL  DERANGEMENT  OF  THE  KNEE. 

THE  knee  joint  is  occasionally  the  seat  of  a  peculiar  kind  of 
accident,  which,  for  want  of  a  better  name,  was  called  internal 
derangement  by  Hey,  who  first  described  it.  It  is  extremely 
painful;  it  occurs  during  perfect  health  from  most  trivial 
causes;  if  it  happens  once  it  is  always  liable  to  occur  again;  and 
after  a  time  the  joint  is  very  likely  to  become  seriously  crippled. 
Yet,  mainly  owing  to  the  fact  that  opportunities  of  examining 
the  interior  of  the  joint  are  seldom  met  with,  its  pathology  is 
almost  as  much  a  matter  of  discussion  as  ever  it  was. 

It  is  undoubtedly  connected  with  two  flattened  structures 
in  the  joint  known  as  the  semilunar  cartilages.  Roughly 
speaking,  they  form  two  circles,  lying  side  by  side  between  the 
bones.  The  margin  of  each  is  the  thickest  part;  from  this 
they  slope  off  gradually  toward  the  centre,  where  there  is  a 
perforation.  The  circumference,  especially  that  of  the  internal 
one,  is  attached  to  the  bone  more  or  less  firmly  all  round ;  but 
the  part  corresponding  to  the  centre  of  the  joint,  where  the 
two  cartilages  touch  each  other,  is  much  the  most  secure.  At 
this  point  each  of  them  is  interrupted  for  a  short  distance,  and 
the  four  ends  so  formed  are  firmly  united  to  the  bone  beneath. 
The  outer  cartilage  forms  nearly  a  complete  circle,  so  that 
its  ends  lie  close  together;  the  inner,  on  the  other  hand,  barely 
forms  two-thirds  of  one.  This  peculiarity  of  shape,  and  the 
presence  of  several  accessory  bands,  tend  to  make  the  inner 
of  the  two  the  more  secure.  It  scarcely  moves  at  all  in  ordi- 
nary actions  of  the  joint,  merely,  when  the  weight  falls  on  it, 
expanding  a  little  in  all  directions  from  its  centre.  The  outer 
one,  on  the  other  hand,  glides  backward  and  forward  freely. 

It  is  generally  supposed  that  in  a  typical  case  of  internal 
derangement  one  or  the  other  of  these  cartilages  slips  from 
its  position  and  is  caught  between  the  bones.  As  a  conse- 


Sprains ;  their  Consequences  and  Treatment.  173 

quence  the  movement  of  the  joint  is  abruptly  checked;  com- 
plete extension  becomes  impossible;  the  two  bones  are  forcibly 
wedged  apart  from  each  other,  and  the  ligaments  that  hold 
them  together  are  stretched  and  strained.  The  internal,  in 
spite  of  its  greater  security,  suffers  more  often;  the  external, 
perhaps  from  the  very  way  in  which  it  can  accommodate  itself, 
nearly  always  escapes. 

Rupture  of  the  Semilunar  Cartilages. — Sometimes  they 
are  torn  completely  away  from  their  attachments.  Godlee 
mentions  one  instance  in  which  the  external  was  found  rolled 
up  toward  the  centre  of  the  joint,  having  been  separated  from 
the  bone  all  around  the  margin.  Annandale  has  described  the 
anterior  end  of  the  internal  one,  stretched  or  wrenched  away 
from  the  bone;  and  probably  they  may  be  injured  in  other 
ways  as  well,  torn  across,  for  example,  or  twisted  round  in 
various  fashions,  or,  if  the  violence  is  sufficiently  severe,  forced 
out  from  the  joint  altogether  until  they  project  beneath  the 
skin.  Then  there  is,  generally  speaking,  laceration  of  the 
lateral  or  of  the  internal  ligaments  of  the  joint  as  well,  so  that 
the  bones  are  dislocated  from  each  other. 

If  the  joint  is  the  seat  of  chronic  synovitis,  or  is  subject  to 
attacks  of  rheumatic  gout,  or  if,  in  younger  people,  there  is 
that  peculiar  loosened  condition  of  the  ligaments  which  I  have 
already  described,  the  displacement  may  be  much  more  com- 
plicated. It  is  not  unusual  to  find  in  these  circumstances  that 
the  cartilages  may  be  made  to  slip  backward  and  forward 
between  the  bones  by  the  mere  pressure  of  the  finger.  It  is 
not  fair,  however,  to  regard  these  as  genuine  examples  of  in- 
ternal derangement.  In  this,  the  joint  is,  to  all  appearance, 
perfectly  sound  and  healthy;  the  violence  is  exceedingly 
slight ;  and  the  relief  is  instantaneous.  There  may  be  a  tran- 
sient effusion  into  the  cavity  of  the  joint  after  the  displace- 
ment has  taken  place,  but  clearly  there  can  be  no  tearing  or 
even  severe  bruising  of  any  of  the  internal  structures.  The 
greatest  injury  must  fall  short  of  this,  or  the  time  required  for 
repair  would  naturally  be  much  longer. 

Displacement  Without  Rupture. — The  best  description  is 
given  by  Knott,  of  Dublin,  who  has  suffered  from  it  himself 
on  repeated  occasions.  It  first  occurred  to  him  when  he  was 
a  boy,  as  he  was  walking  quietly  along.  All  of  a  sudden, 
without  having  sustained  any  wrench  or  twist  of  which  he  was 


1/4  Sprains;  their  Consequences  and  Treatment. 

conscious,  he  was  seized  with  such  agonizing1  pain  on  the  inner 
side  of  the  knee  joint  that  he  half  fell,  half  sat  down,  on  the 
ground,  sick  and  faint,  with  a  sensation  of  utter  helplessness. 
The  knee  was  slightly  flexed ;  he  could  not  move  it  one  way  or 
the  other,  and  voluntary  power  over  it  was  entirely  lost.  In- 
stinctively he  applied  his  hands  one  on  either  side  of  the  joint, 
and  made  as  powerful  a  pressure  as  he  could  in  the  hope  of 
relieving  the  suffering.  This  caused  the  flexion  to  diminish ; 
when  suddenly  the  pain  again  became  almost  intolerable,  a 
clicking  sensation  was  conveyed  to  his  hand  and  his  ear  at  the 
same  time,  and  perfect  relief  came  at  once.  He  managed  to 
walk  away,  and  no  after  trouble  of  any  kind  followed. 

After  that  the  accident  happened  to  him  on  many  occa- 
sions; he  noticed  that  it  never  occurred  during  active  move- 
ment, but  only  when  the  muscles  were  off  their  guard;  and 
that  if  the  knee-joint  was  slightly  bent,  the  least  force  applied 
so  as  to  turn  the  toes  outward  was  sufficient  to  cause  it.  So 
long  as  he  walked  with  the  toes  turned  in  the  joint  felt  secure; 
the  reverse  of  this  is  the  case  when  the  displacement  concerns 
the  external  of  the  two  cartilages. 

From  this  he  is  convinced  that,  at  least  in  his  own  case,  the 
displacement  consists  in  the  posterior  part  of  the  internal 
cartilage  gliding  forward  from  its  position  until  it  is  caught 
between  the  bones.  This  forces  them  apart,  like  a  wedge,  and 
completely  stops  the  movement  of  the  joint.  The  muscles 
round  contract  at  once,  and  become  perfectly  rigid,  so  that 
voluntary  action  is  out  of  the  question  for  the  time.  After- 
ward, when  they  are  tired  out,  and  the  joint  fills  with  fluid, 
the  power  of  movement  returns  again;  but  complete  exten- 
sion is  not  possible  so  long  as  the  displacement  lasts. 

Hey's  account  is  closely  similar.  He  describes  the  knee  as 
being  not  unf requently  affected  with  an  internal  derangement 
of  its  component  parts,  as  a  consequence  of  trifling  accidents, 
and  states  that  the  trouble  is  now  and  then  removed  as  sud- 
denly as  it  is  produced,  by  the  natural  movement  of  the  joint, 
without  surgical  assistance  of  any  kind;  but  that  it  may  re- 
main for  weeks  or  months,  and  then  become  a  serious  misfor- 
tune, as  it  causes  a  considerable  degree  of  lameness. 

"  The  disorder  may  happen  with  or  without  contusion.  In 
the  former  the  symptoms  are  equivocal,  until  the  effects  of 
the  contusion  are  removed.  When  no  contusion  has  happened, 


Sprains ;  their  Consequences  and  Treatment.  175 

or  when  the  effects  of  it  are  removed,  the  joint,  with  respect  to 
its  shape,  appears  uninjured.  If  there  is  anjT  difference  from 
its  usual  appearance,  it  is  that  the  ligament  of  the  patella  ap- 
pears more  relaxed  than  in  the  sound  limb.  The  leg  is  readily 
bent  and  extended  by  the  hands  of  the  surgeon,  and  without 
pain  to  the  patient.  At  most,  the  degee  of  uneasiness  caused 
by  this  flexion  or  extension  is  trifling,  but  the  patient  himself 
cannot  freely  bend  or  extend  the  limb  in  walking;  he  is  com- 
pelled to  walk  with  an  invariable  and  small  degree  of  flexion ; 
yet  in  sitting  down  the  affected  joint  will  move  like  the 
other." 

Bonnet,  from  experiments  on  the  dead  subject,  confirms 
Knott's  views  of  what  takes  place  in  these  cases,  and  shows 
clearly  that  it  is  produced  by  twisting  the  leg  outward  when 
the  limb  is  slightly  flexed.  Certainly  there  is  no  laceration  or 
extensive  displacement  of  any  internal  structure.  Sir  Astley 
Cooper  wrote  of  it  in  much  the  same  terms,  stating  that  it 
may  be  produced  by  striking  the  inner  side  of  the  great  toe 
against  any  slight  projection,  when  the  knee  is  bent  as  in 
walking.  I  have  seen  the  same  thing  myself  on  several  occa- 
sions, but  the  most  interesting  example  with  which  I  am  ac- 
quainted was  told  me  by  a  medical  man  of  himself.  During  his 
student  days,  while  playing  at  football,  he  suddenly  made  a 
violent  kick,  missed  his  aim,  and  fell  down,  feeling  very  sick, 
with  intense  pain  on  the  inner  side  of  his  knee.  He  was  entirely 
unable  to  move  the  joint,  but  after  a  friend  had  slowly  flexed 
the  limb  as  much  as  he  could,  and  then  rapidly  extended  it, 
the  pain  disappeared  all  of  a  sudden,  and  he  could  walk  as 
before ;  only  for  some  days  there  was  a  considerable  amount  of 
swelling,  and  a  sense  of  insecurity  about  the  joint.  The  same 
thing  happened  to  him  on  several  occasions  afterward. 

These  symptoms  agree  so  closely  with  those  described  by 
Hey,  Knott,  and  Bonnet,  that  there  can  be  no  doubt  the  actual 
derangement  is  the  same,  though  the  way  in  which  it  is  pro- 
duced is  apparently  altogether  different.  I  say  apparently, 
because,  if  the  action  of  the  knee  joint  under  these  conditions 
is  considered  for  a  moment,  the  difference  completely  disap- 
pears. When  the  leg  is  extended,  just  as  it  comes  to  lie  in  the 
same  straight  line  with  the  thigh,  a  slight  amount  of  rotation 
outward  takes  place  at  the  knee  joint,  so  that  the  ligaments 
become  tense,  and  the  joint  sufficiently  secure  to  bear  the 


176  Sprains;  their  Consequences  and  Treatment. 

weight  of  the  body  in  walking.  In  this  particular  instance 
extension  was  extremely  rapid  and  vigorous;  there  was  no 
weight  resting  on  the  limb  to  keep  the  bones  in  apposition, 
and,  consequently,  there  was  nothing  to  check  the  rotation 
outward.  This  allowed  the  posterior  margin  of  the  internal 
cartilage  to  be  carried  forward  until  it  was  caught  and  fixed 
by  the  spasmodic  contraction  of  the  muscles.  Voluntary 
movement  at  once  became  out  of  the  question.  I  have  since 
been  told  that  accidents  of  a  similar  character,  only  not  suf- 
ficiently severe  to  cause  any  actual  displacement,  are  not  un- 
common at  football;  there  is  merely  a  sickening  pain  on  the 
inner  side  of  the  joint  for  a  few  minutes,  and  in  some  instances 
a  slight  amount  of  effusion  afterward;  but  the  displacement 
is  not  carried  far  enough  for  the  cartilage  to  be  caught  and 
fixed. 

Reduction. — The  method  of  reduction  has  been  already 
mentioned;  nothing  is  easier  when  once  it  is  understood,  es- 
pecially if  the  patient  is  under  an  anaesthetic.  Hey  recom- 
mended making  him  sit  on  a  high  chair,  facing  the  surgeon, 
who  should  grasp  the  limb  firmly,  extend  it  until  it  was  as 
straight  as  the  circumstances  wrould  allow,  and  then  rapidly 
flex  it  again.  Later  surgeons  have  reversed  this  proceeding 
with  some  advantages,  as  preliminary  extension  is  much  more 
painful  than  flexion,  and  in  the  second  step  rapid  flexion  is 
somewhat  difficult  to  carry  out.  Whichever  way  is  adopted, 
while  it  is  being  done  firm  pressure  must  be  made  with  the 
thumb  of  the  disengaged  hand  over  the  position  of  the  displaced 
cartilage.  As  soon  as  free  movement  is  restored  the  limb  is 
carefully  padded  with  cotton  wool,  and  thoroughly  bandaged  to 
prevent  any  accidental  redisplacement,  and  to  limit  the  effu- 
sion that  is  almost  certain  to  follow 

After  Treatment. — This  apparently  trivial  precaution 
should  never  be  omitted.  The  chief  danger  of  this  singular 
accident  is  its  extraordinary  liability  to  occur  again  and  again. 
If  the  effusion  is  not  checked  at  once  the  capsule  and  the  liga- 
ments yield  until  the  natural  tension  of  the  joint  is  lost,  and 
the  displacement  becomes  easier  than  ever.  When  once  a 
commencement  has  been  made  these  two  things  act  and  react 
continually  on  each  other;  each  displacement  causes  a  fresh 
amount  of  effusion;  each  time  the  effusion  occurs  it  makes 
the  displacement  more  easy.  At  length  it  often  happens  that 


Sprains;  their  Consequences  and  Treatment.  1/7 

the  distention  becomes  chronic  and  that  the  joint  is  seriously 
disabled,  though  it  must  be  admitted  that  when  this  has 
happened  the  displacement  does  not  cause  so  much  pain  as 
it  did. 

After  the  effusion  has  been  absorbed  it  is  always  advisable 
to  wear  a  retentive  apparatus  for  some  months,  especially 
when  indulging-  in  any  exertion  which,  like  lawn-tennis,  has  a 
particular  tendency  to  produce  this  derangement.  If  it  has 
only  happened  once,  an  elastic  knee-cap,  strengthened  and 
padded  opposite  the  internal  cartilage,  may  suffice;  but  care 
must  be  taken  with  an  appliance  of  this  description  that  more 
harm  than  good  does  not  result.  It  must  never  be  worn  at 
night ;  and  when  it  is  taken  off  the  knee  should  be  thoroughly 
rubbed  and  kneaded  to  restore  the  circulation  through  it,  or 
else  the  tissues  waste  away  and  the  elastic  becomes  so  com- 
fortable that  it  is  regarded  by  the  patient  as  indispensable. 

If  one  of  the  attachments  of  the  cartilage  has  been  torn,  so 
that  there  is  a  definite  displacement  recognized  by  the  projec- 
tion it  forms  beneath  the  skin,  on  the  outer  or  the  inner  side 
of  the  joint,  this  is  not  sufficient.  Either  a  mechanical  con- 
trivance must  be  worn  for  the  purpose  of  checking  irregular 
movements  of  the  leg  when  the  lateral  ligaments  are  slightly 
relaxed,  or  else,  as  Annandale  has  done  on  several  occasions, 
with  conspicuous  success,  the  joint  must  be  opened,  and  the 
offending  cartilage  stitched  into  position. 

A  very  good  arrangement  for  cases  of  this  kind  consists  of 
two  well-padded  metal  plates  accurately  fitted  round  the 
knee-cap,  one  on  either  side  and  held  together  above  and  below 
by  short  straps.  These  plates  are  connected  together  by  a 
steel  spring  passing  horizontally  across  behind  the  joint,  so 
that  when  the  splint  is  in  position  they  press  firmly  on  the 
unprotected  portion  of  the  capsule,  where  the  displacement  is 
most  likely  to  occur.  If  this  does  not  answer,  or  if  it  is  thought, 
from  an  examination  of  the  case,  that  the  derangement  in  the 
case  of  the  internal  cartilage  is  really  due  rather  to  outward 
rotation  of  the  leg  while  the  ligaments  are  relaxed,  the  best 
kind  of  apparatus  is  formed  on  the  principle  of  two  lateral 
bars  jointed  opposite  the  knee,  and  connected  together  above 
and  below  by  a  circle  round  the  limb,  formed  partly  of  metal 
and  partly  of  leather.  An  additional  strap  across  the  joint 
above  and  below  the  patella  is  sometimes  of  service.  This  is 


178  Sprains;   their  Consequences  and  Treatment. 

heavier  and  more  cumbersome,  but  much,  more  efficient  than 
the  former  in  checking-  irregular  movements  of  rotation  in 
either  direction.  Flexion  and  extension  are  not  in  the  least 
impeded,  and  after  the  patient  has  once  grown  accustomed  to 
it  even  lawn-tennis  is  possible  in  it. 


CHAPTEE  XIY. 

CONTRACTION  OF  THE  FINGERS. 

IT  sometimes  happens  that  sprains,  instead  of  running  an 
ordinary  course,  are  liable  to  be  followed  by  unusual  results, 
due  either  to  some  peculiarities  of  structure  in  the  part  itself, 
or  to  the  presence  of  an  overpowering1  constitutional  taint,  or 
to  the  influence  of  both  together.  One  of  these,  which  occurs 
in  the  hand,  tying  down  the  fingers,  and  giving  rise  to  serious 
inconvenience  from  the  way  in  which  it  interferes  with  their 
movements,  is  known  as  Dupuytren's  contraction. 

Structure. — The  whole  of  the  palm  of  the  hand  is  invested 
by  a  sheet  of  dense  fibrous  tissue,  which  forms  a  sheath  round 
all  the  muscles,  and  is  closely  united  to  the  skin  on  one  surface 
and  the  bones  on  the  other.  In  the  centre  it  is  exceedingly 
strong,  stretching  over  the  tendons  and  retaining  them  securely 
in  all  the  movements  which  the  hand  executes.  It  is  to  this, 
in  great  measure,  that  the  palm  owes  its  firm  resisting  feel. 
At  the  sides,  where  it  is  continued  over  the  muscles  of  the 
thumb  and  little  finger,  the  thickness  is  not  so  gre<it;  but 
where  these  portions  join  the  central  part  there  are  two  strong 
partitions  passing  deeply  toward  the  back  of  the  hand,  and 
sending  off  side  branches  in  a  direction  parallel  to  the  surface 
between  the  deeper  structures.  At  the  clefts  of  the  fingers 
the  central  part  breaks  up  into  four  divisions,  each  of  which 
again  divides,  so  as  to  form  bands  running  down  the  sides 
until  they  become  attached  to  the  bones  and  the  sheaths  of 
the  tendons.  Where  the  division  takes  place,  and  the  several 
portions  commence  to  diverge,  another  layer,  lying  deeper 
than  the  tendons,  comes  to  reinforce  it  from  below,  and  just 
here  it  is  very  closely  attached  to  the  skin.  Sometimes,  as  a 
result  of  strains,  this  fibrous  tissue  slowly  but  almost  irre- 
sistibly contracts,  until  the  ring  and  little  fingers,  and  some- 
times even  the  middle  one,  are  rigidly  flexed  into  the  palm  of 


180  Sprains ;  their  Consequences  and  Treatment. 

the  hand  so  that  no  reasonable  amount  of  force  can  straighten 
them  again. 

The  first  thing  to  attract  attention  is  the  presence  of  a  small 
hard  nodule  in  the  palm  of  the  hand,  at  a  point  corresponding 
to  the  lowest  of  the  transverse  creases  into  which  the  skin  is 
thrown,  and  to  the  interval  between  the  ring  and  little  fingers. 
It  is  not  painful  unless  pressed  upon  or  roughly  handled,  and 
does  not  at  first  give  rise  to  any  inconvenience ;  there  is  merely 
a  hardened  inelastic  spot,  where  the  tissues  are  bound  together 
so  that  they  do  not  yield  and  give  way  to  each  other  in  every 
movement  as  they  ought.  Soon,  however,  the  skin  begins  to 
waste  and  lose  its  flexibility;  the  fat  disappears,  and  it  be- 
comes tied  down  to  the  fascia  beneath  so  firmly  that  it  is  prac- 
tically incorporated  with  it.  Then  prolongations  may  be 
noticed  running  from  this  point  upward  toward  the  wrist, 
and  downward  to  the  fingers.  The  latter  are  much  the 
stronger,  and  if  the  process  continues,  the  ring  and  little  fingers 
become  more  and  more  flexed  by  the  contraction  of  these  bands 
until  they  are  held  down  immovably  in  the  palm.  One  of 
these  two  fingers  is  generally  the  first ;  but  often  both  of  them 
suffer,  and  sometimes  the  middle  and  even  the  index  are  affected 
as  well.  When  the  bending  is  complete,  the  finger  catches  in 
.everything  like  a  hook,  so  that  it  is  liable  to  be  pulled  back 
and  hurt  at  any  moment,  and  becomes  the  source  of  extreme 
annoyance  from  the  way  in  which  it  interferes  with  every 
action,  even  such  apparently  trivial  matters  as  shaking  hands. 

Cause. — Dupuytren  was  the  first  to  point  out  the  cause  of 
this  deformity,  and  it  has  ever  since  been  known  by  his  name. 
He  showed  that  the  flexion  and  subsequent  rigidity  were  dus 
entirely  to  the  contraction  of  the  fascia  by  the  side  of  the  fin- 
gers, and  that  the  tendons  themselves  took  no  share  of  any 
kind  in  its  production.  They  are  and  remain  perfectly  free. 
It  is  not,  however,  quite  so  simple  a  process  as  it  appears  to 
be  from  this;  the  shortening  does  not  take  place  merely  in  one 
direction.  If  the  part  is  carefully  examined,  the  first  thing 
that  is  noticed  is  a  depression  of  the  skin  where  it  is  tied  down 
to  the  tissues  beneath.  The  shrinking  is  general ;  the  fibrous 
tissue  contracts  in  all  directions,  and  the  change  is  made  more 
conspicuous  still  by  the  absorption  of  the  fat,  and  the  wasting 
of  the  soft  parts  as  the  blood-vessels  become  more  and  more 
constricted. 


Sprains ;  their  Consequences  and  Treatment.  181 

It  is  this  which  renders  the  difficulty  of  effective  treatment 
so  great.  If  the  contraction  merely  took  place  in  one  direc- 
tion, simple  division  of  the  shortened  band  would  be  sufficient. 
Unhappily  this  is  rarely  the  case.  The  whole  of  the  fibrous 
tissue  of  the  palm  at  the  affected  spot  becomes  so  dense  and 
rig-id  that  such  a  proceeding-  scarcely  produces  any  effect. 
The  contraction  is  as  great  in  depth  as  it  is  in  length.  The 
fat  is  absorbed ;  the  muscle  wasted ;  the  skin  loses  it  supple- 
ness and  flexibility,  and  the  texture  is  so  chang-ed  that  in  ad- 
vanced cases  the  whole  of  the  tissue  between  it  and  the  bones 
beneath  appears  to  be  converted  into  a  dense  fibrous  mass, 
which  creaks  and  grates  under  the  knife  when  an  attempt  is 
made  to  divide  it. 

Much  of  the  interest  that  is  always  expressed  about  this 
deformity  arises  from  its  supposed  connection  with  g-out.  It 
is  believed  by  many  that  this  alone,  without  injury  of  any 
kind,  is  sufficient  to  produce  it.  It  is  certainly  true  that  it  is 
much  more  common  among-  men  than  women,  and  that  many 
more  cases  are  met  with  in  private  practice  where  g-out  is 
frequent  than  among-  hospital  patients;  but  it  hardly  seems 
probable  that  this  can  be  the  only  cause. 

If  this  is  the  case,  it  is  not  a  little  singular  that  a  French- 
man should  have  been  the  first  to  give  a  true  account  of  its 
pathology ;  and  even  if  the  presence  of  this  complaint  is  ad- 
mitted as  one  of  the  reasons  for  the  obstinate  persistence  of 
this  contraction,  it  hardly  seems  probable  that  it  can  be  the 
sole  cause  of  its  commencement.  In  a  certain  proportion  of 
cases  it  is  impossible  to  obtain  any  history  of  gout,  either  in 
the  patients  themselves,  or  even  in  their  families;  and  though 
it  is  more  commonly  met  with,  it  is  true,  after  middle  life,  it 
certainly  does  occur  long  before.  I  have  seen  it  as  early  as 
one-and-twenty,  and  one  of  the  worst  cases  that  has  ever 
come  under  my  notice  (it  was  so  bad  that  one  of  the  fingers 
was  amputated)  was  in  a  man  only  four  years  older. 

Urate  of  soda,  too,  is  rarely  found  in  connection  with  this, 
unless  there  is  a  general  deposit  in  other  parts  of  the  bodj7 ; 
and,  so  far  as  I  know,  this  form  of  contraction  has  never  been 
described  in  connection  with  the  feet,  though  it  is  notorious 
gout  has  a  special  predilection  for  this  region,  and  there  is  a 
layer  of  fascia  in  them  almost  identical  in  structure  and  ar- 
rangement with  that  of  the  palm  of  the  hand.  The  immediate 


1 82  Sprains ;   their  Consequences  and  Treatment. 

cause  is  either  a  single,  sudden  strain,  bending-  the  fingers 
back,  or  long-continued  irritation,  such  as  that  produced  by 
the  constant  pressure  of  a  round-headed  stick  in  the  palm  of 
the  hand,  especially  during  convalescence  from  illness.  Gout 
very  probably  is  one  of  the  conditions  that  predispose  to  its 
occurrence,  but  it  is  almost  certain  that  it  is  not  the  only  one. 

It  is  more  common  among  the  upper  and  middle  classes 
(or,  perhaps,  it  would  be  more  correct  to  say  that  they  more 
commonly  apply  for  relief)  than  among  laborers,  because  in 
these  the  hands  are  thoroughly  hardened  and  trained  to  work 
of  all  kinds,  and  a  strain  that  would  cause  serious  injury  in 
the  one  is  hardly  felt  by  the  other.  It  does,  however,  occur 
among  out-patients,  especially  among  those  who  are  employed 
in  engineers'  shops;  I  have  seen  many  such  cases,  and  have 
been  assured  by  the  men  that  quite  half  of  their  number  are 
affected  more  or  less,  only  they  do  not  consider  it  worth  while 
applying  for  relief.  With  regard  to  this  it  is  significant  that, 
among  the  class  of  people  who  furnish  the  majority  of  the  out- 
patients in  a  general  hospital,  it  is  almost  as  common  among 
women  as  it  is  among  men. 

The  comparative  weakness  of  the  fingers  on  the  inner  side 
of  the  hand  is  sufficient  to  account  for  the  fact  that  they  are 
affected  almost  exclusively.  The  muscles  attached  to  them 
are  so  much  weaker  that  they  are  unable  to  stand  a  strain 
that  is  at  all  sudden  or  severe,  and  give  way  before  a  force  the 
others  can  bear  with  ease. 

It  is  the  obstinate  and  progressive  character  of  this  con- 
traction that  renders  it  so  serious.  When  once  it  has  com- 
menced, though  it  may  remain  quiescent  for  long  periods,  it 
has  on  the  whole  a  decided  tendency  to  grow  worse  and  worse. 
In  the  earlier  stages  it  may  be  relieved,  or  even  cured,  without 
great  difficulty;  in  the  later  ones  this  is  impossible  without 
operation,  and  sometimes  this  condition  becomes  so  bad  that 
the  patient  prefers  the  permanent  and  distressing  deformity 
of  losing  his  finger. 

Treatment. — Before  contraction  has  made  its  appearance, 
when  there  is  only  a  small  hard  nodule  to  be  felt  beneath  the 
skin,  the  very  simple  device  of  repeatedly  working  the  part 
with  the  thumb  of  the  other  hand,  while  the  fingers  support 
the  back,  is  often  sufficient  to  arrest  its  progress,  only  it  must 
be  carried  out  regularly  and  systematically.  Rotatory  motion, 


Sprains ;  their  Consequences  and  Treatment.  183 

with  the  affected  finger  well  stretched  out,  so  as  to  make  the 
contraction  tense,  is  the  most  useful,  changing  the  direction 
now  and  then,  and  keeping  up  firm  pressure  all  the  while.  If 
this  is  carefully  carried  out  every  day,  or  better  still  two  or 
three  times  a  day,  and  if  at  the  same  time  further  flexion  is 
checked  by  constantly  straightening  out  the  fingers  and  the 
palm,  pressing  them  spread  out  upon  a  table  or  other  firm  ob- 
ject, the  tendency  can  certainly  be  kept  in  check  for  years. 
Too  often,  however,  this  precaution  is  so  simple  that  it  is  neg- 
lected, and  when  advice  is  sought  the  contraction  is  already 
wrell  marked  and  the  skin  firmly  adherent. 

Even  then  much  may  be  accomplished  by  the  same  means, 
supplemented  by  the  use  at  night  of  an  appliance  devised  to 
exercise  a  certain  amount  of  continuous  traction.  In  the  later 
stages,  and  after  operations,  some  contrivance  of  this  descrip- 
tion is  essential.  When  the  deformity  is  only  slight,  I  have 
found  an  ordinary  wooden  splint,  firmly  padded  opposite  the 
knuckles,  very  useful.  It  must  be  well  fastened  by  means  of 
straps  and  buckles  to  the  wrist  and  the  two  first  fingers;  and 
little  caps  made  of  some  soft  metal,  such  as  thin  sheet  lead, 
fitted  on  to  the  under  surface  between  the  affected  joints. 
Steady  continuous  traction  can  then  be  made  on  these  at  night 
by  means  of  elastic  bands;  and,  if  the  angle  is  still  more  than 
a  right  angle,  a  great  amount  of  improvement  can  generally 
be  effected  in  a  comparatively  short  space  of  time. 

Where  the  flexion  is  more  advanced,  or  where  an  operation 
has  been  performed,  so  simple  a  contrivance  is  rarely  sufficient. 
It  is  generally  necessary  to  have  an  appliance  constructed  by 
an  instrument-maker.  The  principle  on  which  they  work  is 
essentially  the  same.  There  is  a  broad,  well-padded  metal  plate 
fitted  to  the  back  of  the  hand,  so  as  to  be  quite  firm,  and  pro- 
vided with  extension  racks  lying  over  the  fingers,  and  bent  at 
an  angle  to  suit  the  deformity.  This  is  buckled  on  of  an  even- 
ing, and  screwed  up  until  the  desired  position  is  obtained. 

The  difficulty  is  to  graduate  the  tension  with  sufficient 
nicety.  On  the  one  hand  the  continued  use  of  the  instrument 
becomes  exceedingly  irksome,  unless  a  certain  amount  of  im- 
provement is  visible ;  on  the  other,  there  is  the  pain  due  to  the 
tension  on  the  fibrous  structures  of  the  palm,  and  the  fear  of 
injury  to  the  skin  from  pressure.  It  is  a  rough  but  fair  rule, 
when  no  operation  has  been  performed,  to  straighten  out  the 


184  Sprains ;  their  Consequences  and  Treatment. 

fingers  each  time  as  far  as  the  patient  will  allow  them;  and 
then  to  relax  again  slightly.  Progress  must  be  slow,  and,  if 
the  degree  of  pain  is  at  all  severe,  the  patient,  as  a  rule,  refuses 
,  to  continue,  and  remains  satisfied  with  a  slight  and  temporary 
degree  of  improvement.  Care  must  be  taken  as  often  as  the 
splint  is  removed,  and  again  before  it  is  applied,  to  knead  the 
tissues  of  the  palm  thoroughly,  and  to  soak  the  hand  in  water 
as  hot  as  can  be  borne;  otherwise  a  great  deal  of  the  benefit 
that  may  be  derived  from  the  extension  is  almost  certain  to 
be  lost. 

An  immense  amount  of  improvement  in  the  method  of  oper- 
ating has  been  effected  in  recent  years  by  the  ingenuity  of 
various  orthopaedic  surgeons,  and  especially  William  Adams. 
Dupuytren  himself  merely  made  a  transverse  incision  through 
the  skin  and  fascia,  at  the  most  resisting  point,  so  that  when 
the  finger  was  straightened  out  there  was  a  lozenge-shaped 
wound,  the  sides  of  which  might  in  successful  cases  grow  to- 
gether. This,  however,  rarely  happened;  the  wound  nearly 
always  had  to  heal  by  granulating,  and  the  resulting  cicatrix 
possessed,  as  it  always  does  under  these  conditions,  so  great  a 
power  of  contraction  that  the  deformity  was  reproduced  often 
in  a  worse  degree.  I  have  seen  a  finger  irretrievably  tied 
down  within  a  month  by  the  cicatrization  of  a  comparatively 
superficial  wound  along  its  under  surface,  not  deep  enough  to 
involve  either  the  tendon  or  its  sheath. 

This  was  improved  upon  first  by  Goyrand,  who,  before 
dividing  the  contracting  band,  made  a  longitudinal  incision 
through  the  skin  so  as  to  improve  the  chance  of  primary  union. 
In  some  cases  (those,  for  example,  in  which  the  contraction  is 
deep  rather  than  broad,  and  does  not  involve  more  than  one 
finger)  this  answers  fairly  well,  especially  as  the  means  for 
securing  early  union  are  much  better  understood  at  the  present 
day.  The  skin  must  be  detached  first  on  either  side  with  the 
greatest  care,  and  the  band,  besides  being  completely  divided, 
must  be  separated  as  far  as  possible  from  its  deep  connections 
by  incisions  parallel  to  the  surface.  When  so  much  as  this  is 
done,  however,  it  is  more  satisfactory  to  isolate  the  whole  of 
the  contracted  tissue  from  its  surroundings,  and  remove  it 
bodity.  I  have  known  this  done  on  several  occasions  with  the 
most  excellent  results.  The  most  serious  objection  is  that, 
when  the  adhesions  are  spread  over  any  extent  of  surface,  a 


Sprains ;   their  Consequences  and  Treatment.  185 

great  deal  of  manipulation  is  required  to  detach  the  skin,  and, 
consequently,  there  is  some  danger  of  impairing1  its  power  of 
recovery.  If  it  does  perish,  the  wound  that  is  left  is  large, 
though  superficial,  and  there  is  a  great  tendency  to  contraction, 
so  that  in  cases  where  the  lateral  extent  is  considerable  it  is,  as 
a  rule,  advisable  to  select  another  method. 

For  this  reason,  as  soon  as  the  merits  of  subcutaneous 
tenotomy  became  known,  other  methods  were  almost  entirely 
superseded.  At  first  the  band  was  divided  in  one  single  spot, 
without  much  benefit  resulting.  Then  a  totally  different  plan 
was  adopted,  minute  punctures,  as  many  as  may  be  required, 
being  made  wherever  the  contraction  stood  out  prominently 
beneath  the  skin,  recollecting  that  the  shrinking  is  a  general 
one,  taking  place  equally  in  all  directions.  The  number  is  not 
regarded  as  of  any  moment.  The  object  is  to  divide  the  con- 
traction thoroughly,  wherever  it  resists,  and  to  separate  it 
from  the  parts  beneath. 

The  palm  of  the  hand  is  dealt  with  first,  selecting  those 
points  where  the  skin  is  movable  over  the  subjacent  tissue; 
then  each  side  of  the  affected  fingers  by  itself.  The  skin 
wounds  are  scarcely  visible ;  there  is  little  or  no  bleeding,  and 
if  they  are  covered  up  at  once,  and  firm  pressure  made  with 
little  pads  of  lint,  they  ought  to  be  perfectly  sound  within  three 
days.  No  attempt  at  extension  must  be  made  until  they  are. 

Where  the  position  of  the  fingers  is  such  as  to  allow  it, 
massage  is  of  great  assistance,  both  as  a  preliminary  measure 
and  in  the  after  treatment  of  the  case.  It  loosens  the  attach- 
ment of  the  skin,  gets  rid  of  the  thickened  epidermis,  so  that 
the  wounds  close  more  accurately,  and  does  away,  to  a  great 
extent,  with  the  necessity  of  detaching  it  from  its  deep  con- 
nection. But  three  clear  days  at  least  must  be  allowed  to  pass 
before  the  operation.  There  is  always  a  certain  amount  of 
hyperasmia  attendant  on  kneading  and  manipulation,  and 
under  these  conditions  this  is  not  advisable. 

After  the  punctures  have  healed,  massage  is  of  even  greater 
service.  There  is  no  fear  of  their  being  reopened  if  sufficiently 
firm  pressure  is  emplo3red.  The  surface  is  fixed  in  this  way,  so 
that  no  tension  can  fall  on  them ;  while  the  lymph  that  fills  up 
the  interstices  of  the  deep  incisions  is  dispersed,  and  driven  into 
the  absorbents,  so  that  the  amount  of  fresh-formed  cicatricial 
tissue,  and  the  danger  of  recontraction,  are  both  of  them  re- 


1 86  Sprains ;   their  Consequences  and  Treatment. 

duced  to  a  minimum.  It  is  not  uncommon,  where  the  operation 
has  been  thoroughly  carried  out,  to  find  the  hard  nodules,  left 
behind  at  first,  becoming-  smaller  and  smaller,  until  they 
either  disappear  altogether  or  cease  to  give  rise  to  any  trouble. 
Extension,  by  means  of  instruments,  should  be  steadily 
employed,  at  first  all  day  long-,  and  then,  according  to  the 
progress  made,  at  night  only.  The  same  general  rules  must  be 
observed  as  when  no  operation  has  been  performed,  not  going 
too  fast,  for  fear  of  reopening  the  punctures  and  injuring  the 
skin,  or  too  slow,  for  then  the  contracting  bands  will  reform 
and  reproduce  the  deformity.  As  a  rule,  it  is  advisable  to 
make  as  much  progress  as  possible  during  the  early  days,  for 
then  the  tissues  that  unite  the  severed  portions  are  still  soft 
and  yielding.  If  it  is  to  be  successful,  the  whole  must  be  accom- 
plished within  three  weeks,  though  the  appliance  must  be  worn 
for  some  time  longer  on  account  of  the  danger  of  recontraction. 


CHAPTEE  XY. 

MUSCULAR  CONTRACTION. 

IN  speaking  of  the  results  of  sudden  twists  and  sprains, 
it  was  mentioned  that  the  muscles  and  tendons  rarely  escape 
altogether,  and  it  was  pointed  out  that  sometimes,  even  when 
the  joints  are  not  concerned,  they  sustain  very  serious  injuries 
from  being  crushed  or  bruised,  and,  perhaps,  torn  in  two,  in 
the  effort  they  make  to  save  the  joint.  This,  however,  is  not 
all.  Though  there  may  be  no  visible  effect  at  the  time,  it  is 
not  uncommon  for  changes  in  the  nutrition  or  the  activity  of 
the  muscles  to  make  their  appearance  at  a  later  period,  and  to 
become  worse  and  worse  as  time  goes  on,  until  they  interfere 
seriously  with  the  use  of  the  limb,  and  lead,  perhaps,  to  very 
grave  results. 

These  may  be  distinguished  from  those  already  described 
as  secondary  or  remote.  There  is  no  fixed  time  for  their  occur- 
rence. They  may  appear  within  the  first  few  days,  or  three  or 
four  weeks,  or  even  more  may  pass  without  any  change  being1 
noticed,  and  their  variety  is  almost  unlimited.  Some  are  prob- 
ably the  result  of  inflammation,  as  when  groups  of  extensor 
muscles,  to  the  complete  exclusion  of  the  rest,  waste  or 
atrophy  shortly  after  the  injury.  Others  appear  to  be  de- 
pendent on  some  morbid  condition  of  the  nervous  system. 
Many  are  the  direct  consequence  of  the  accident,  without  which 
they  would  never  have  occurred ;  many  more,  like  those  com- 
plaints known  as  hysterical,  are  merely  the  local  manifesta- 
tion of  a  general  condition,  determined  to  one  particular  part 
by  the  occurrence  of  the  accident.  Some  few  are  still  only 
capable  of  a  conjectural  explanation. 

Cramp. — In  some  instances  the  muscular  contraction  is  of 
a  very  simple  character,  when,  for  example,  after  some  sudden 
strain,  a  particular  group,  or  set,  becomes  hard  and  tense,  and 
passes  almost  at  once  into  a  state  of  spasmodic  rigidity.  It 
may  last  for  the  instant  only,  subsiding  of  itself,  and  merely 


1 88  Sprains ;  their  Consequences  and  Treatment. 

leaving  the  part  stiff  and  tender  for  the  next  day ;  or  if  the 
tension  is  not  relieved  it  may  be  kept  up  until  exhaustion  com- 
pels the  fibres  to  relax.  When  this  occurs,  as,  for  example,  in 
internal  derangement  of  the  knee,  the  joint  is  said  to  be  locked. 
So  far  as  the  patient  himself  is  concerned  it  is  fixed  entirely 
beyond  control.  Except  by  making  use  of  his  hands  to  move 
it,  or  by  placing  it  in  such  a  position  that  the  weight  of  the 
limb  can  bear  upon  it,  he  has  not  the  least  power  over  it.  The 
spasm  does  not  yield  until  the  cause  has  been  removed  by 
manipulation,  or  by  other  suitable  measures.  It  is  the  direct 
result  of  the  strain ;  the  muscles  and  nerves  are  stretched,  and 
their  ends  dragged  asunder,  either  by  the  accident  itself  or  by 
the  displacement  of  some  internal  structure.  This  acts  as  a 
stimulus.  The  contraction  is  the  result,  and,  until  some  relief 
is  afforded,  voluntary  movement  is  out  of  the  question. 

The  pain  in  sudden  twists  of  the  loin  or  neck,  when,  for  in- 
stance, the  head  is  quickry  turned  round  for  the  purpose  of 
looking  at  something  above  and  behind,  is  in  many  cases  due 
to  this.  The  attack  is  always  sudden ;  the  pain  very  severe, 
often  sufficient  to  make  the  patient  cry  out,  and  for  the  mo- 
ment he  feels  as  if  it  were  impossible  to  move.  Then  the  head 
is  slowly  and  cautiously  brought  round  again  to  the  natural 
position  with  a  perceptible  sense  of  effort.  In  a  few  of  these 
there  is  dislocation  or  rupture  of  some  of  the  slender  muscular 
slips  that  lie  by  the  side  of  the  vertebral  column,  or  bruising 
of  the  delicate  tissue  round  and  between  the  smaller  joints. 
Accidents  of  this  kind  are  well  known  to  occur  occasionally, 
and  some  instances  have  been  already  mentioned.  At  first 
the  symptoms  are  very  much  alike,  but  there  is  rarely  any 
difficulty  in  distinguishing  them  afterward.  The  cramp  due 
to  a  sudden  strain  disappears  much  sooner  than  the  others; 
relief  is  rapid  and  often  spontaneous ;  a  feeling  of  soreness  may 
persist,  it  is  true,  for  days,  but  the  part  can  be  used  at  once 
with  a  fair  degree  of  freedom.  In  the  other  cases,  owing  to 
the  tearing  and  laceration  at  the  time  of  the  injury,  the  effects 
are  much  more  serious.  They  last  a  longer  time,  and  it  is 
often  necessary  for  the  patient  to  submit  to  a  long  and  careful 
course  of  treatment  before  the  part  is  recovered  sufficiently  to 
be  used  again  with  comfort. 

The  muscular  cramp,  which  is  so  common  after  unusual  ex- 
ertions, among  those  especially  who  have  a  tendency  toward 


Sprains ;  their  Consequences  and  Treatment.  189 

gout,  bears  a  close  resemblance  to  this.  It  is  true  that  the 
immediate  cause  is  very  trivial,  as  a  rule,  and  that  the  con- 
traction rarely  involves  the  whole  of  the  muscle,  but  the  differ- 
ence almost  disappears  if  due  allowance  is  made  for  the  con- 
dition of  the  tissues  at  the  time.  Instead  of  being-  fresh  and 
active,  they  are  tired  out  from  overwork;  waste  products, 
probably  of  an  acid  nature,  accumulate  in  their  substance,  and 
there  is  need  of  a  long  period  of  repose  before  the  blood  circu- 
lating through  them  can  restore  their  strength  and  vigor.  In 
these  circumstances  a  very  insignificant  stimulus  is  sufficient 
to  excite  contraction.  Merely  holding  the  limb  in  an  awkward 
position  will  cause  it.  Some  fibres  are  unduly  stretched. 
Suddenly  they  swell  up,  become  hard,  nodular,  and  painful; 
and  then,  as  they  tire  themselves  out,  slowly  relax  and  be- 
come soft  again,  leaving  the  part  sore  and  tender.  The  mus- 
cles, which  preserve  the  most  perfect  sequence  of  action  so 
long  as  they  are  fresh,  become  more  and  more  irritable  as  thejr 
are  exhausted,  so  that  their  fibres  are  thrown  into  a  state  of 
irregular  and  spasmodic  contraction  by  stimuli,  which,  under 
ordinary  conditions,  would  not  have  the  least  influence  on  them. 

The  remedy  is  to  straighten  out  the  muscle  quietly,  but 
firmly,  with  as  little  delay  as  possible.  The  patient  is  gener- 
ally unable  to  do  it  for  himself,  and  then  it  must  be  done  for 
him.  The  head,  for  example,  must  be  steadily  and  firmly 
brought  round  until  it  faces  the  opposite  direction.  If  this  is 
done  before  complete  rigidity  sets  in  the  pain  and  tenderness 
are  much  less  severe.  At  the  same  time  great  relief  may  be 
obtained  by  kneading  and  rubbing  any  hard  or  contracted 
mass  that  can  be  felt  under  the  skin,  the  pressure  following 
the  course  of  the  fibres  until  they  relax  and  become  soft  again. 
Where  the  resistance  is  very  obstinate  spongiopiline,  or  flannel 
wrung  out  of  water  as  hot  as  can  be  borne,  may  be  applied  with 
benefit,  and  if  the  tenderness  is  extreme  the  rubbing  may  be 
continued  with  an  anodyne  liniment.  As  a  rule,  it  is  fairly  easy 
to  make  the  contraction  subside,  but  it  is  as  well  to  caution 
the  patient  to  be  careful  afterward  about  the  position  in  which 
the  part  is  held.  If  the  muscle  is  slightly  strained  again,  or 
kept  in  a  state  of  tension  before  recovery  is  perfect,  the  cramp 
is  very  likely  to  return  at  the  same  spot,  and  be  much  more 
painful. 

It  does  not  seem  improbable,  from  what  is  known  of  the 


190  Sprains ;  their  Consequences  and  Treatment. 

use  of  massage  in  restoring1  the  energy  of  overworked  muscles 
and  relieving  the  pain  of  sudden  strains,  that  great  benefit 
might  be  derived  from  it  in  those  cases  in  which  the  limbs  or 
particular  groups  of  muscles  are  liable  to  be  seized  with  cramp 
at  frequent  intervals,  without  there  being  any  definite  cause  to 
account  for  it,  other  than  the  presence  of  some  impurity  in  the 
blood.  It  has  a  most  wonderful  influence  on  the  circulation 
and  nutrition;  it  relieves  the  exhaustion  of  fatigue  more 
thoroughly  and  rapidly  than  anything  else ;  and  it  is  only  rea- 
sonable to  think  that  if  it  were  systematically  applied  the 
same  effects  would  follow  in  cases  such  as  these. 

Tonic  Contraction. — Muscular  rigidity  after  sprains  is 
not,  however,  always  instantaneous  or  spasmodic;  sometimes 
it  comes  on  quietly  and  slowly,  and  persists  without  any  ap- 
parent relaxation  for  an  almost  indefinite  time.  It  is  not  pain- 
ful so  long  as  it  is  left  alone;  the  joint  is  merely  held  rigidly 
fixed  in  one  position  until  the  tissues  become  wasted  and 
spoiled  for  want  of  use. 

In  Children. — One  variety  is  often  met  with  in  children, 
and,  as  Paget  has  shown,  may  be  regarded  as  in  some  degree 
the  result  of  fear,  though  it  can  hardly  be  due  to  this  alone. 
The  main  features  in  the  history  are  nearly  always  the  same. 
Some  joint  has  been  slightly  strained;  perhaps  it  is  the  elbow, 
owing  to  the  way  in  which  children  are  swung  round  by  the 
hands.  A  few  days  after,  it  is  noticed  that  the  arm  is  held 
continuously  in  one  position,  and  then  it  is  found  that  the 
muscles  on  one  side  of  the  limb  are  in  a  state  of  rigid  contrac- 
tion, which  is  maintained  so  long  as  the  child  is  awake.  Any 
attempt  at  straightening  it  out  meets  with  steady  resistance 
and  a  peculiar  elastic  recoil.  If  the  attention  is  diverted,  or, 
in  a  still  greater  degree,  if  the  child  is  placed  under  the  in- 
fluence of  an  angesthetic,  the  joint  can  be  moved  freely  and 
easily,  so  that  it  is  clear  there  are  no  adhesions  or  fibrous  con- 
tractions round.  Nothing  is  out  of  place;  there  is  no  sign  of 
inflammation;  the  stiffness  is  purely  muscular.  It  cannot  be 
called  voluntary ;  children  cannot,  by  any  effort  of  will,  keep  a 
limb  straight  and  rigid  for  hours ;  nor  is  it  due  to  reflex  dis- 
turbance starting  from  the  joint,  for  not  only  does  it  involve 
muscles  (e.g.,  the  extensors  of  the  knee)  which  would  never  be 
involved  in  this  way,  but  the  contraction  shifts  at  times  rapidly 
from  one  set  to  another,  and  even  from  one  joint  to  another. 


Sprains ;  their  Consequences  and  Treatment.  191 

It  is  not  even  necessary  that  a  joint  should  be  involved  at 
all.  One  of  the  most  obstinate  cases  I  have  ever  seen  was  in 
a  boy  who  had  a  small  ganglion  on  the  back  of  his  wrist;  this 
had  been  ruptured  subcutaneously  twice  before,  but  each  time 
it  filled  again,  as  they  often  will.  If  it  was  even  touched,  all 
the  muscles  on  the  back  of  the  forearm  quite  involuntarily  be- 
came rigid,  so  that  any  attempt  at  bending-  the  fingers  caused 
severe  pain.  When  the  ganglion  was  removed  all  the  con- 
traction disappeared  at  once,  and  did  not  return. 

Now,  in  some  instances,  no  doubt,  this  is  the  unconscious 
result  of  fear.  The  joint  has  been  hurt  once,  and  the  child  in- 
stinctively keeps  it  stiff  to  prevent  its  being  hurt  again.  But 
this  is  not  all.  The  child  really  has  not  the  power  of  straight- 
ening out  the  muscles,  and  the  longer  the  case  lasts  the  more 
marked  the  inability  becomes.  Voluntary  control  is  not  yet 
throughly  developed.  The  emotional  side  of  the  mind  is 
stronger  than  the  will,  and  muscular  contraction  such  as  this 
takes  place  because  there  is  not  the  power  to  help  it. 

The  diagnosis  seldom  presents  much  difficulty.  Self-con- 
sciousness in  children  is  not  perfect  enough  to  be  constantly  on 
its  guard ;  sooner  or  later  something  occurs  to  distract  their 
attention  from  themselves,  the  crippled  limb  is  forgotten,  and 
the  rigidity  vanishes,  to  return  again  instantly  if  the  part  is 
touched.  In  sleep,  too,  it  rarely  persists,  and  it  is  seldom 
necessary,  even  in  the  most  doubtful  cases,  to  resort  to  the  use 
of  anaesthetics.  It  is  quite  exceptional  in  them  for  the  con- 
traction to  last  long  enough  to  excite  any  organic  change  in 
the  muscular  substance  or  the  structure  of  the  joint;  and  the 
mimicry  of  inflammation  is  rarely  perfect.  Either  the  posi- 
tion is  exceptional,  as  when  the  knee  is  kept  straight  instead 
of  flexed,  or  the  temperature  of  the  skin  is  never  raised,  or 
something  so  unusual  or  incongruous  is  present,  that  the  sug- 
gestion of  serious  joint  disease  is  put  out  of  court  at  once. 

Treatment. — In  many  of  these  cases,  where,  for  instance,  a 
limb  has  been  kept  obstinately  fixed  in  one  position  for  some 
length  of  time,  it  is  almost  impossible  to  dispense  entirely  with 
the  use  of  splints,  but  it  is  as  well  to  employ  them  as  little  as 
possible.  The  object  is  to  strengthen  the  limb,  and  to  accustom 
the  muscles  to  act  in  obedience  to  the  will,  not  to  confine  them 
or  to  restrict  their  action.  Much  more  may  be  effected  by 
quietly  making  the  position  of  the  limb  uncomfortable,  varying 


192  Sprains ;  their  Consequences  and  Treatment. 

the  method  according  to  the  particular  circumstances  of  each 
case.  A  mild  counter-irritant,  for  example,  may  be  applied  in 
the  angle  where  one  surface  presses  on  another :  this  is  gen- 
erally sufficient  to  induce  the  patient  to  alter  the  position  of 
the  limb,  without  anything  further,  but  care  must  be  taken 
not  to  blister  the  skin,  which  is  certain  to  be  soft  and  tender  at 
this  spot. 

In  other  cases  it  answers  better  to  leave  the  contraction 
entirely  alone,  and  to  divert  the  attention  successively  to 
different  parts  of  the  body.  I  have  seen  several  instances  in 
which  this  method  of  treatment  has  been  followed  by  con- 
spicuous success;  and  though  the  cure  may  not  have  been  per- 
manent, yet  time  was  gained  for  the  adoption  of  other  meas- 
ures, and  the  danger  of  degenerative  changes  avoided.  Quite 
recently,  two  children  were  brought  to  me  separately  on  the 
same  day  for  exactly  the  same  affection.  In  each  a  knee  had 
been  sprained  some  time  before,  and  the  limb  had  become  stiff 
and  rigid  in  a  position  of  extreme  extension.  The  least  at- 
tempt at  bending  it  caused  severe  pain.  There  was  no  heat 
or  redness,  or  any  sign  of  inflammation,  and  certainly  there 
was  no  displacement.  Acting  on  a  suggestion  of  one  of  the 
friends,  a  small  blister  was  placed  in  each  case  on  the  knee  of 
the  opposite  leg,  with  the  best  result ;  free  movement  returned 
within  twenty-four  hours. 

It  must  not  be  forgotten,  however,  that  this  method  of 
treatment  does  not  aim  at  permanent  success;  it  merely  re- 
lieves the  symptoms  of  the  moment,  and  prevents  the  occur- 
rence of  serious  after-consequences.  It  has  no  influence  of  any 
kind  on  the  real  cause,  which  is  nearly  always  some  disordered 
condition  of  the  general  health.  Until  this  is  set  right  by  meas- 
ures, which,  of  course,  must  vary  in  each  individual  case,  it  is 
almost  hopeless  to  look  forward  to  any  lasting  benefit  from 
other  plans. 

In  Adults. — Muscular  rigidity  of  this  description  is  not 
confined  to  children.  It  is  nearly  as  common  in  young  adult 
life  in  one  sex  as  well  as  the  other,  and  is  liable  to  be  followed 
by  consequences  of  a  much  more  serious  character.  Sometimes 
it  come  on  suddenly,  so  that  the  patient  on  waking  up  of  a 
morning  is  unable  to  straighten  out  a  limb ;  sometimes  it  is  so 
slow  and  gradual  that  no  one  can  quite  call  to  mind  when  it 
first  appeared;  there  has  only  been  a  stiffness,  increasing 


Sprains ;  their  Consequences  and  Treatment.  193 

gradually  from  day  to  day,  until  some  accidental  circumstance 
calls  attention  to  it. 

Many  of  these  cases  resemble,  in  their  chief  features,  those 
already  described.  They  are  in  reality  the  result  of  defective 
voluntary  control.  Mental  power  has  either  never  been  de- 
veloped thoroughly  or  else  it  is  not  exercised.  It  may  be  that 
it  has  remained  in  the  state  so  characteristic  of  childhood,  or 
that  it  has  become  entirely  subordinate  to  an  excessive  long-- 
ing- for  sympathy.  Whatever  it  is,  the  cause  is  not  any  mis- 
chief in  the  joint;  there  is  no  disease  or  inflammation  in  the 
part,  though  there  may  be  a  close  resemblance  to  it.  How- 
ever serious  the  final  result,  and  it  may  end  in  complete  loss 
of  use,  at  any  rate  at  the  beginning,  the  contraction  can  only 
be  regarded  as  the  local  expression  of  a  constitutional  weak- 
ness, which  may  show  itself  in  a  variety  of  ways. 

Simulation  of  Joint  Disease. — The  most  striking  feature 
about  it  is  the  way  in  which  it  can  imitate  real  disease.  The 
resemblance  is  sometimes  extraordinary.  In  the  one  case  the 
joint  is  inflamed  and  the  muscles  are  tightly  contracted,  be- 
cause the  least  movement  of  the  bones  causes  intense  pain ;  in 
the  other,  the  rigidity  is  merely  the  act  of  an  emotional  or  an  ex- 
cited frame  of  mind,  of  little  importance  in  itself,  and  serious 
only  in  proportion  to  the  likelihood  of  its  continuance  and  the 
secondary  changes  that  follow.  Yet  the  difficulty  is  some- 
times extreme,  and  it  is  not  lessened  by  the  fact  that  it  is  ad- 
visable to  come  to  a  definite  conclusion,  and  adopt  suitable 
measures  as  soon  as  may  be.  Whatever  the  cause,  if  left  to 
itself  it  is  a  condition  only  likely  to  become  steadily  worse. 

Fortunately,  the  evidence,  if  it  is  properly  interpreted,  is 
clear  and  distinct  in  the  great  majority  of  cases.  In  some,  the 
first  glance  is  enough.  There  is  a  certain  order  and  regularity 
present  in  the  symptoms  when  a  joint  is  inflamed;  they  vary, 
it  is  true,  according  to  the  joint,  but,  for  each  individual  one 
they  are  fairly  constant,  and  if  there  is  any  glaring  inconsis- 
tency, such  as  is  met  with  sometimes,  the  idea  of  inflammation 
may  be  set  aside  without  hesitation.  In  others,  however,  the 
question  is  not  so  easily  answered,  and  it  is  only  after  repeated 
examination  and  the  most  careful  weighing  of  evidence  that 
such  a  conclusion  can  be  formed. 

The  previous  history  is  of  very  little  use.  Very  often, 
without  the  least  intention  of  deceiving,  it  is  entirely  mislead- 


194  Sprains;  their  Consequences  and  Treatment. 

ing-.  If  at  any  time,  no  matter  how  remote,  there  was  an  ac- 
cident, the  symptoms  are  always  dated  from  it,  and  if  nothing- 
deserving-  of  such  a  name  can  be  remembered,  repeated  ques- 
tioning is  sure  to  sug-g-est  it  at  length.  It  is  only  in  accordance 
with  human  nature  that,  as  a  result  of  continued  trying,  vague 
recollection  should  become  a  definite  picture,  the  details  grow- 
ing more  and  more  circumstantial  each  time  until  the  whole 
thing-  is  clear,  and  the  friends  at  least  are  thoroughly  con- 
vinced. As  a  matter  of  fact,  it  is  not  unusual  for  them  to  be 
much  more  certain  on  such  a  point  as  this  than  the  patient 
himself. 

Nor  is  any  great  degree  of  help  to  be  derived  from  the 
position  of  the  limb.  In  cases  of  emotional  contraction  in  chil- 
dren it  is  often  unusual  or  inconsistent  with  the  presence  of  in- 
flammation, as  when  the  knee  is  kept  rigidly  extended,  but  in 
adults  it  is  commonly  identical  with  that  assumed  in  real  dis- 
ease. So  with  the  locality  in  which  pain  is  felt.  This  may 
correspond  exactly,  even  in  such  strange  features  as  pain  on 
the  inner  side  of  the  knee  when  the  hip  joint  is  inflamed. 

Sometimes  the  difficulty  is  increased  by  the  addition  of 
symptoms  that  are  ordinarily  regarded  as  characteristic  of 
inflammation.  The  part,  for  example,  may  be  swollen,  and  the 
temperature  of  the  skin  raised ;  there  may  even  be  a  distinct 
blush  upon  the  surface;  but  close  examination,  even  in  cases 
such  as  these,  nearly  always  reveals  their  true  character.  The 
increase  in  size,  for  example,  is  never  very  distinct;  often  it 
appears  to  be  more  considerable  than  it  is,  from  the  wasting- 
of  some  of  the  tissues  and  the  passive  collection  of  fluid  in 
others ;  the  rise  of  temperature  (which  should  always  be  esti- 
mated by  a  surface  thermometer;  the  hand  may  easily  be  de- 
ceived) is  never  above  that  which  is  normal  in  the  more  pro- 
tected parts  of  the  body,  and  the  blush,  if  it  were  really  due 
to  inflammation,  would  indicate  a  degree  of  severity  that  is 
certainly  not  present. 

In  many  instances  information  may  be  g-ained  from  the 
length  of  time  that  has  elapsed  since  the  accident,  or  at  least 
since  the  commencement  of  the  symptoms.  Muscular  rigidity 
is  one  of  the  earliest  signs  of  inflammation,  but  it  never  re- 
mains the  only  one.  At  a  very  early  period  others  are  sure 
to  make  their  appearance,  and  as  they  become  more  numerous 
and  more  marked  the  diagnosis  becomes  more  easy.  Emo- 


Sprains ;   their  Consequences  and  Treatment.  195 

tional  contraction,  on  the  other  hand,  may  last  for  an  indefinite 
period  with  no  further  change  than  that  which  has  been  already 
described  as  the  result  of  prolonged  inaction. 

Unhappily  the  methods  that  are  so  successful  in  children 
do  not  give  nearly  such  certain  evidence  in  the  case  of  adults. 
In  the  former  it  is,  comparatively  speaking,  easy  to  divert  at- 
tention from  a  suspected  joint,  so  that  if  it  is  not  inflamed  the 
tonic  contraction  of  the  muscles  quietly  disappears  and  the 
angle  changes.  In  the  latter  it  is  much  more  difficult.  Chance 
moments  of  forgetfulness  seldom  present  themselves  in  them, 
and  the  case  may  be  watched  for  a  very  considerable  time 
without  any  change  being  detected. 

Sometimes  after  all  the  evidence  has  been  carefully  weighed 
it  seems  impossible  to  arrive  at  a  definite  conclusion.  There 
is  then  only  one  alternative;  the  patient  must  be  placed  under 
an  anaesthetic.  This  rarely  fails.  The  joint  may  then  be  ex- 
amined without  the  least  pain;  the  muscles  are  completely 
relaxed;  the  movements  are  not  interfered  with;  and  it  be- 
comes possible  to  ascertain  definitely  how  much  of  the  rigidity 
is  due  to  spasmodic  contraction,  and  how  much  to  other  causes. 
It  often  happens  that  a  limb,  apparently  as  rigid  as  a  bar  of 
iron,  becomes  perfectly  flexible  as  soon  as  sensibility  is  lost. 

There  is,  too,  as  Paget  has  pointed  out,  another  advantage 
to  be  gained  by  doing  this.  Valuable  information  may  often 
be  obtained  by  carefully  watching  the  condition  of  the  muscles 
while  the  patient  is  coming  round  again.  If  the  rigidity  is  due 
to  the  pain  of  an  inflamed  joint  they  begin  to  contract  and 
steady  the  bones  long  before  consciousness  has  returned ;  and 
they  do  it  so  gradually  and  imperceptibly  that  it  is  almost  im- 
possible to  say  when  the  change  commences.  The  rigidity  is 
an  instinctive  act,  independent  altogether  of  the  mind  or  of  the 
higher  cerebral  centres,  and  it  returns  of  itself  long  before 
these  have  reassumed  their  influence.  When,  on  the  other 
hand,  no  such  cause  is  present,  the  relaxation  continues  until 
some  notice  is  taken  of  it;  then  it  disappears  almost  instan- 
taneously, and  the  muscles  become  even  more  rigid  than  they 
were  before. 

At  first  sight  it  appears  improbable,  but  it  is,  nevertheless, 
true,  that  the  danger  of  overlooking  the  presence  of  inflamma- 
tion is  not  nearly  so  great  as  that  of  imagining  that  it  exists 
when  the  real  cause  is  the  lack  of  voluntary  control  and  pro- 


196  Sprains ;  their  Consequences  and  Treatment. 

longed  disuse.  It  is,  comparatively  speaking1,  rare  for  disease, 
even  of  such  an  obscure  and  deep-seated  joint  as  the  hip,  to 
be  mistaken  for  hysteria;  the  opposite  is  much  more  common. 

Not  Merely  Hysteria. — This,  however,  is  not  the  only  reason 
why  these  cases  of  emotional  contraction  deserve  special  at- 
tention. There  is  another  danger  to  which  they  are  exposed, 
scarcely  less  serious  and  infinitely  more  frequent.  It  is  one  of 
the  commonest  mistakes  to  regard  a  case  in  which  it  is  clear 
there  is  no  inflammation,  merely  as  hysterical,  and  to  dismiss 
it  summarily  as  the  product  of  some  transient  phase  of  mental 
emotion.  The  joint  is  hysterical,  and  that  is  enough;  local 
treatment  is  not  required;  indeed,  it  is  considered  by  many  to 
be  actually  injurious,  as  it  tends  still  further  to  attract  the 
attention  of  the  patient  to  the  part;  general  measures  only 
are  recommended,  and  the  contraction  is  left  entirely  to  itself. 

The  result  might  be  anticipated.  As  I  have  described 
already,  a  part  that  is  kept  at  rest  and  never  used  cannot  re- 
main healthy;  certain  changes  inevitably  make  their  appear- 
ance; they  need  not  be  gross  ones,  or  produce  conspicuous 
alterations ;  the  nutrition  of  the  part  suffers,  and  that  is  quite 
enough;  the  tissues  are  impoverished  and  lose  the  power  of 
working  with  that  complete  unconsciousness  and  absence  of 
effort  which  is  so  characteristic  and  striking  a  feature  of 
health. 

A  good  example  of  this  may  frequently  be  met  with  in  the 
case  of  the  arm,  because,  from  the  ease  with  which  the  shoulder- 
blade  moves  upon  the  chest  the  shoulder-joint  itself  can  be  kept 
almost  at  rest  for  an  indefinite  period  without  attracting  much 
attention.  The  patient  is  almost  always  a  young  girl;  there 
may  be  a  history  of  injury;  more  often  this  cannot  be  relied 
on ;  or  there  may  have  been  some  mental  trouble.  At  any 
rate,  there  is  sure  to  have  been  something  that  either  receives, 
or  wants,  the  constantly  and  loudly  expressed  sympathy  of 
others.  The  symptoms  at  first  do  not  seem  in  any  way  imper- 
ative; there  is  always  a  certain  amount  of  pain,  which  is  borne 
with  much  resignation ;  and  the  movement  of  the  part  is  con- 
strained and  awkward,  especially  when  any  attempt  is  made 
to  raise  the  hand  above  the  level  of  the  shoulder;  but  there 
is  nothing  apparently  serious  until  the  part  is  examined  and 
compared  with  the  opposite  side.  Then  it  is  found  that  all  ths 
time  the  shoulder-joint  itself  has  been  kept  perfectly  quiet,  and 


Sprains ;   their  Consequences  and  Treatment.  197 

that  the  clumsiness  is  due  to  the  attempt  that  has  been  made 
by  one  joint  to  supply  the  place  of  two.  The  muscles  are 
wasted ;  the  bony  prominences  stand  out  unduly ;  the  rounded 
contour  is  lost;  the  arm  cannot  be  lifted  from  the  side;  rotat- 
ing- the  limb  is  almost  impossible ;  the  soft  tissues  round  the 
joint  have  become  firm  and  unyielding-,  and  the  patient  is  un- 
able to  raise  the  hand  to  the  back  of  the  head.  The  joint  is 
almost  rig-id ;  the  whole  of  the  movement,  or  nearly  the  whole, 
is  apparent  only,  and  is  really  due  to  the  freedom  and  ease 
with  which  the  shoulder-blade  glides  upon  the  chest. 

A  joint  in  this  condition  cannot  be  called  hysterical.  It  is 
of  no  consequence  whether  it  originated  in  hysteria  or  not. 
The  starting-  point  of  the  contraction  may  have  been  an  injury, 
or  it  may  not;  that  has  nothing-  to  do  with  it.  The  joint  has 
been  kept  at  rest  and  never  used;  its  tissues  are  starved  and 
wasted ;  and  they  are  unable  to  do  their  work.  It  is  no  long-er 
a  question  of  want  of  voluntary  power;  the  muscles  are  rig-id 
and  the  soft  tissues  round  are  stiff  and  unyielding-;  and  until 
their  natural  condition  is  restored  by  local  measures  the  part 
cannot  work,  whether  the  patient  has  the  power  to  will  it  or 
not.  The  fault  may  have  been  that  of  the  patient  originally, 
but  now  it  has  passed  entirely  out  of  her  control. 

This  is  even  more  serious  than  it  appears  at  first  sight.  A 
joint  that  is  stiff  and  painful  is  always  liable  to  become  the 
seat  of  hysteria,  even  when  this  is  not  the  cause.  The  patient's 
health  suffers;  every  attempt  at  movement  causes  pain;  the 
existence  of  the  joint  is  continually  being  forced  upon  the  mind, 
it  is  impossible  to  forget  its  condition,  and  at  length  it  may 
happen  that  from  this  alone,  even  in  those  who  are,  compara- 
tively speaking,  strong  of  will,  a  condition  closely  resembling 
hysteria,  if  not  identical  with  it,  becomes  developed.  It  is  for 
this  reason  that  active,  vigorous  local  treatment,  such  as  I 
have  described  already  in  speaking  of  the  effects  of  prolonged 
disuse,  is  so  essential  in  the  treatment  of  what  are  called  hys- 
terical joints.  Until  the  nutrition  is  thoroughly  restored,  and 
the  tissues  have  recovered  their  natural  power,  it  is  hopeless 
attempting  to  effect  any  improvement  by  general  methods. 
The  two  lines  of  treatment  must  be  carried  on  together;  one 
without  the  other  is  almost  useless.  It  savors  of  the  ridiculous 
to  assure  the  friends  of  a  patient  that  if  the  condition  of  the 
joint  could  only  be  forgotten  recovery  would  follow  at  once, 


198  Sprains ;  their  Consequences  and  Treatment. 

when  all  the  time  the  tissues  are  too  wasted  to  do  their  work, 
and  the  least  attempt  at  movement  causes  pain. 

Muscular  Contraction  from  other  Causes. — Now  and  then 
instances  are  met  with  which  cannot  be  explained  by  any  of 
these  causes.  Some  accident,  apparently  quite  trivial  in  char- 
acter, is  followed  by  persistent  muscular  contraction,  without 
the  least  trace  either  of  hysteria  or  inflammation  to  account 
for  it.  One  of  these  that  came  under  my  notice  recently  was 
in  many  ways  most  striking1.  The  patient  was  a  young-  man, 
tall,  and  of  good  muscular  development.  While  at  sea,  about 
a  twelvemonth  before  I  saw  him,  he  had  strained  his  knee  in 
getting  out  of  the  hatch.  His  account  of  the  accident  was 
perfectly  clear.  He  had  to  take  a  step  of  great  height  to  ob- 
tain a  purchase  for  his  foot,  and  to  raise  himself  up  at  the 
same  time  with  his  hands;  while  doing  this,  pulling  on  his 
knee  joint  with  all  the  strength  of  which  he  was  capable,  from 
a  position  of  extreme  flexion,  he  felt  something  snap;  there 
was  a  moment  of  intense  pain,  and  he  fell  back  almost  help- 
less. When  his  knee  was  examined  it  was  full  of  fluid,  but 
there  was  no  displacement,  and  it  was  not  locked.  It  was 
thought  at  the  time  that  it  was  merely  a  sprain,  and  that  if  it 
was  kept  bandaged  for  a  week  it  would  get  quite  well.  In 
spite  of  this,  however,  it  was  nearly  a  month  before  he  could 
rest  any  weight  on  it;  and  even  before  this  he  noticed  that 
the  muscles  which  bend  the  joint  were  slowly  contracting,  and 
that  he  was  gradually  losing  the  power  of  straightening  it 
out.  This  grew  worse  and  worse,  until  at  length  he  was  so 
disabled  that  he  was  forced  to  lay  up  and  consult  a  surgeon, 
who  placed  him  under  an  anaesthetic  and  straightened  the  limb 
by  main  force.  He  could  walk  better  after  this,  but  he  was 
still  compelled  to  wear  a  leather  splint  to  keep  the  joint  ex- 
tended. As  soon  as  he  left  it  off  the  knee  began  to  bend  itself 
in  a  manner  entirely  beyond  control,  and,  of  a  morning  par- 
ticularly, it  was  only  after  great  effort,  and  with  much  pain, 
that  he  was  able  to  stand  upright.  To  complete  his  misfort- 
une, he  had  slipped  off  the  curb -stone  and  sprained  his  knee 
again  only  a  few  days  before.  Since  this  the  loss  of  control 
had  been  worse  than  ever;  it  was  only  with  the  greatest  effort 
that  he  could  get  the  limb  straight  at  all ;  the  morning  that  I 
saw  him  he  had  fainted  twice  in  the  attempt;  his  health  was 
failing,  and  he  was  reduced  by  pain,  and  by  the  loss  of  his  ap- 
pointment, almost  to  a  state  of  despair. 


Sprains ;   their  Consequences  and  Treatment.  199 

On  removing1  the  splint  it  was  at  once  apparent  that  the 
whole  limb  was  wasted  to  a  certain  extent  from  pressure,  but 
mainly  from  disuse.  There  was  no  discoloration,  swelling,  or 
pain;  and  the  only  tender  spot  was  the  one  on  the  inner  side 
of  the  knee  cap,  of  which  almost  all  patients  complain.  The 
muscles  on  the  front  of  the  thigh  had  suffered  most  severely; 
the  flexor  ones  at  the  back  felt  unusually  firm  and  hard,  though 
their  bulk,  as  compared  with  those  of  the  opposite  side,  had 
diminished  too.  The  strangest  thing-  was,  that  while  looking 
at  him,  the  knee  gradual!}-  began  to  bend,  until  in  about  three 
minutes  it  had  reached  a  right  angle  without  the  patient  hav- 
ing the  least  power  of  preventing  it.  The  movement  was  per- 
fectly smooth  and  quiet.  There  was  no  cramp;  the  ham- 
strings felt  somewhat  firmer,  and  that  was  all.  It  required 
the  exercise  of  very  considerable  strength  to  bring-  the  limb 
again  into  a  straight  position. 

I  recommended  at  first  that  the  limb  should  be  thoroughly 
encased  in  a  plaster  of  Paris  splint,  thinking  that  the  muscles 
would  soon  become  tired  out  by  the  unyielding-  resistance,  as- 
sisted by  the  pressure,  but  it  was  of  no  use;  and  after  being 
on  for  a  few  hours  it  had  to  be  removed  on  account  of  the 
pain.  It  did  not  seem  advisable  to  try  the  action  of  local 
sedatives ;  the  case  had  lasted  too  long  for  them  to  be  of  any 
permanent  service,  and  the  patient  would  not  submit  again  to 
an  anaesthestic,  so  that  it  was  not  possible  to  manipulate  the 
joint  freely.  Under  these  conditions  I  determined  to  try  the 
effect  of  faradization,  applied  to  the  weaker  muscles  on  the 
front  of  the  limb,  and  met  with  the  most  surprising  success. 
During  the  first  application  he  was  able  to  extend  the  limb 
with  much  greater  ease,  and  after  the  third  he  could  do  it 
himself,  when  the  current  was  not  being  applied.  In  short, 
he  was  completely  cured,  and  returned  to  his  occupation, 
though  the  limb,  when  I  saw  him  again  some  months  later, 
had  not  yet  regained  its  normal  proportions. 

There  can  be  no  reasonable  doubt  that  in  this  case  the 
muscular  contraction  was  the  result  of  the  sprain,  though  un- 
happily it  was  impossible  to  ascertain  what  was  the  precise 
nature  of  the  injury  that  had  befallen  him ;  and  no  one  who 
saw  him,  and  who  witnessed  his  anxiety  to  return  to  duty, 
would  have  entertained  for  a  moment  the  suspicion  of  hysteria. 
What  may  have  been  the  explanation  of  the  unbalanced  con- 


2OO  Sprains ;  their  Consequences  and  Treatment. 

traction  is  very  doubtful.  It  seemed  as  if  the  nerves  supplying 
the  weaker  muscles  were  unable  to  convey  a  sufficiently  pow- 
erful stimulus;  that,  to  use  the  phrase  adopted  by  Vivian 
Poore  in  his  Bradshawe  lecture,  they  were  blocked,  so  that 
the  tonic  contraction  of  the  other  muscles  gradually  overcame 
them.  The  muscular  substance  itself  seemed  equally  affected 
on  both  sides  of  the  }imb,  so  that  it  could  scarcely  have  been 
due  primarily  to  this ;  and  there  was  no  reason  to  believe  that 
the  mental  determination  of  the  patient  was  in  any  way  defect- 
ive. It  is  possible,  it  is  true,  that  a  condition  of  irritation 
may  have  been  induced  in  one  of  the  nerve  twigs  supplying 
the  interior  of  the  joint  by  the  changes  following  the  sprain, 
and  that  it  had  travelled,  after  the  fashion  of  the  neuritis  de- 
cribed  by  Erb,  to  the  muscular  branches  supplying  the  flexors, 
stimulating  them  to  increased  and  disproportionate  vigor; 
but,  if  this  were  the  case,  it  is  difficult  to  understand  how  it 
was  so  easily  cured.  Whichever  explanation  is  correct,  it  re- 
mains an  example  of  muscular  contraction,  persisting  for  over 
a  twelvemonth  after  a  sprain,  not  due  to  inflammation  or 
hysteria. 


CHAPTER  XVI. 

MUSCULAR  WASTING. 

WASTING  of  the  muscles  is  another  common  consequence  of 
sprains.  They  lose  their  tone ;  the  firm  elastic  sensation  when 
they  are  pressed  on  with  the  finger  disappears;  they  feel  soft 
and  pulpy;  their  strength  diminishes  and  their  size  decreases 
until,  in  extreme  cases,  they  may  seem  to  have  disappeared 
altogether,  so  plainly  and  distinctly  does  the  outline  of  the 
bones  show  itself  through  the  skin. 

Degeneration  from  Disuse. — There  may  be  many  different 
reasons  for  it.  Want  of  exercise,  for  example,  may  induce  it. 
A  limb  kept  perfectly  at  rest  and  never  used,  of  course,  must 
waste.  The  structure  of  the  tissues  degenerates;  they  either 
become  infiltrated  with  fat  or  replaced  by  it  to  such  an  extent 
sometimes  that  the  real  amount  of  wasting  is  concealed.  The 
muscles  in  some  cases  appear  to  retain  their  normal  shape  and 
size ;  the  outline  of  the  limb  is  nearly  perfect,  but  the  vigor 
and  strength  are  gone,  and  everything  feels  soft  and  inelastic 
to  the  touch.  In  others,  when,  for  instance,  the  patient  is 
suffering  from  some  disease  that  drains  all  his  strength  away, 
the  wasting  is  so  extreme  and  the  amount  of  fat  deposited  so 
slight  that  they  seem  to  have  vanished  altogether,  and  to  leave 
the  bone  covered  in  by  nothing  but  skin. 

This  change  is  a  general  one;  it  affects  all  the  muscles — 
indeed,  all  the  tissues  of  the  limb  alike ;  no  set  or  group  suffers 
perceptibly  more  than  the  rest;  and  unless  the  constitutional 
affection  from  which  the  patient  is  suffering  is  such  as  to  pre- 
clude it,  the  prospect  of  recovery,  so  far  as  the  muscles  are  con- 
cerned, is  exceedingly  good,  even  in  extreme  cases.  There  is 
little  or  no  destruction  of  the  living  active  portion  of  the  mus- 
cle. No  matter  how  diminished  in  size  or  strength  the  residue 
may  be,  as  soon  as  it  is  exercised  and  the  circulation  through 
the  limb  increased  by  general  treatment  (especially  a  liberal 


•  U'JGQ 

IS 

2O2  Sprains ;   their  Consequences  and  Treatment. 

supply  of  food),  assisted  by  local  measures,  such  as  massage 
and  galvanism,  the  size  and  strength  return,  and  in  the  ma- 
jority of  instances  the  whole  of  the  former  vigor  is  regained. 
I  have  seen  this  happen  on  more  than  one  occasion  when  there 
literally  did  not  seem  a  particle  of  muscle  left. 

Wasting  from  Compression. — Wasting  of  a  description  in 
some  respects  similar  to  this  occurs  with  great  rapidity  under 
the  use  of  constant  compression.  The  worst  form  is  caused 
by  the  constriction  of  an  elastic  bandage.  Sometimes  after 
sprains  it  is  thought  advisable  to  wear  one  of  these.  If  there 
has  been  a  great  deal  of  effusion  into  the  cavity  of  the  joint, 
especially  if  it  has  been  allowed  to  remain  unabsorbed  for  any 
length  of  time,  the  capsule  becomes  softened  and  stretches 
until  it  fails  to  exert  any  pressure  on  its  contents.  It  becomes 
loose  and  flaccid,  and  there  is  a  continual  sensation  of  insecurity 
and  want  of  strength.  The  joint  itself  is  actually  firm  enough, 
but  the  patient  does  not  feel  that  it  can  be  trusted  as  it  was 
before.  What  is  the  reason  of  this  is  not  certain ;  it  is  prob- 
ably dependent  on  the  nerves  that  supply  the  joint,  for  the 
same  complaint  is  made  of  muscles  when  the  sheath  of  their 
tendons  is  distended ;  and  it  certainly  supplies  a  very  strong 
argument  in  favor  of  removing  the  surplus  fluid  from  a  joint 
after  an  injury,  by  some  means  or  other,  with  as  little  delay 
as  possible.  However  this  may  be,  when  the  capsule  has  been 
left  in  this  condition  a  patient  often  feels  the  greatest  comfort 
from  the  use  of  an  elastic  support,  such  as  an  anklet  or  knee- 
cap; and,  wearing  it  at  first  only  when  he  is  taking  exercise, 
gradually  continues  it  until  it  is  scarcely  left  off,  even  at  night. 
The  result  may  be  imagined.  In  a  short  time  a  wasted  band 
is  seen  all  round  the  limb  corresponding  accurately  to  the  size 
of  the  elastic;  the  superficial  structures  are  more  affected  than 
the  deeper  ones,  owing  to  the  way  in  which  the  blood  is  kept 
constantly  squeezed  out  of  them ;  and  where  a  muscle  lies  next 
the  skin,  with  a  broad  flat  surface  of  bone  beneath,  it  is  wasted 
to  such  an  extent  that  its  presence  can  scarcely  be  recognized, 
and  years  may  elapse  before  it  recovers.  Such  appliances 
may  be  used  when  any  very  unusual  degree  of  exertion  is  un- 
dertaken, for  just  the  same  reason  that  laborers  strap  a  piece 
of  leather  tightly  round  the  wrist,  but  nothing  can  be  worse 
than  wearing  them  habitually. 

These  kinds  of  wasting  are  not  limited  to  sprains,  and  their 


Sprains ;   their  Consequences  and  Treatment.  203 

influence  is  not  confined  to  the  muscles;  they  are  due  to  gen- 
eral causes,  and  affect  all  the  tissues  of  the  limb,  though,  ow- 
ing- to  their  vascularity  and  softness  of  texture,  there  are 
differences  in  degree.  Others  are  the  direct  consequence  of 
these  injuries,  and  are  different  in  many  points.  They  have 
no  relation  to  disuse;  are  not  the  result  of  compression;  do 
not  involve  equally  all  the  muscles  of  the  limb ;  are  not  due  to 
fatty  degeneration;  and  what  is  more  serious  and  more  im- 
portant than  all  the  rest  together,  unless  active  measures  are 
taken,  sometimes  show  little  or  no  tendency  to  recover. 

Wasting  of  Extensor  Muscles  Only. — One  of  these  affects 
the  extensor  muscles  almost  exclusively,  and  is  remarkable 
both  for  the  very  early  period  at  which  it  shows  itself  and  the 
rapidity  of  its  progress.  I  have  been  able  to  detect  a  distinct 
change  in  the  tone  of  a  muscle  three  days  after  a  sprain,  and 
it  is  common  for  the  diminution  in  size  to  be  visible  at  the  end 
of  a  week.  Simple  rest,  no  matter  how  complete,  does  not 
produce  the  same  result  in  anything  like  the  time.  The  wast- 
ing, too,  is  often  extreme;  a  few  weeks  after  the  receipt  of  a 
strain  or  blow  the  bony  prominences  may  stand  out  with  great 
hollows  between,  so  as,  for  the  moment,  to  give  rise  to  the  idea 
that  something  is  out  of  joint. 

Only  the  extensor  muscles  are  affected,  and  the  -broad  ones 
of  coarser  texture,  such  as  those  covering  over  the  hip  or 
shoulder,  suffer  most,  even  when  full  allowance  is  made  for  the 
peculiarity  of  their  shape.  In  these  two  situations  in  particu- 
lar the  effect  is  so  considerable  that  it  rarely  escapes  notice, 
and  often  is  sufficient  to  attract  the  attention  of  the  patient 
even  before  anything  is  said  about  it. 

At  first  the  wasting  is  limited  entirely  to  this  particular 
group;  the  deltoid,  for  example,  which  gives  the  shoulder  its 
smooth  and  rounded  outline,  is  the  earliest  to  show  the  change ; 
then  it  spreads  to  those  that  cover  in  the  shoulder-blade  be- 
hind. Only  after  it  has  lasted  some  considerable  time  does  it 
involve  the  rest,  and,  as  the  whole  of  the  limb  is  affected  more 
or  less,  then  probably  as  the  result  of  confinement  and  disuse 
rather  than  anything  else.  The  atrophy,  too,  in  these  cases 
is  simple,  and  bears  no  relation  to  fatty  degeneration.  This 
may  set  in  later,  and  involve  all  the  muscles  of  the  limb,  es- 
pecially if  it  is  allowed  to  remain  unused  for  any  length  of 
time;  but  as  Valtat,  in  particular,  has  shown,  both  by  experi- 


204  Sprains ;   their  Consequences  and  Treatment. 

ments  and  clinical  observation,  the  two  processes  are  essentially 
different. 

Many  suggestions  have  been  offered  in  explanation  of  this, 
but  the  most  reasonable  is  that  which  refers  it  to  influences 
exerted  through  the  nerves  supplying  the  joint.  Some  have 
supposed,  as  it  is  common  in  the  shoulder,  that  it  is  the  result 
of  injury  to  a  nerve  which  winds  round  the  bone  in  such  a 
position  that  it  might  easily  be  bruised  in  falls  or  strains. 
But  even  if  this  were  to  happen,  it  does  not  follow  that  the 
muscles  would  become  wasted  in  this  way.  They  certainly  do 
not  when  the  ulnar  nerve  is  bruised,  and,  as  a  matter  of  fact, 
the  wasting  is  not  limited  to  the  muscles  supplied  by  this 
particular  branch,  but  involves  all  those  which  straighten  out 
the  joint,  and  which  are  not  in  any  way  connected  with  it; 
nor  would  this  explanation  be  of  any  service  in  the  case  of 
other  joints,  such  as  the  hip  or  knee. 

Wasting  from  Inflammation. — Wasting  of  this  description 
may  be  taken  as  a  sure  sign  that  the  joint  is  inflamed,  or, 
more  correctly,  that  it  has  been,  for  it  continues  after  the 
other  symptoms  have  subsided.  Its  degree  and  rapidity  de  • 
pend  mainly  on  the  cause  and  severity  of  the  attack.  When 
this  is  but  slight,  affecting  the  vascular  tissues  of  the  joint 
only,  or  due  to  such  transient  local  causes  as  the  tension  set 
up  by  the  accumulation  of  fluid  in  the  interior,  it  is  least 
marked.  If,  on  the  other  hand,  the  deeper  textures  of  the 
joint,  particularly  the  cartilages,  are  involved,  or  if  the  cause 
of  the  inflammation  is  some  condition  of  acute  blood  poison- 
ing, it  is  rapid  and  extreme.  In  children  it  is  not  common, 
unless  at  the  commencement  of  strumous  disease.  Atrophy 
of  the  extensors  never  fails  to  appear  early  in  this,  though, 
owing  to  the  slowly  progressive  nature  of  the  disorder,  it  is 
often  some  time  before  any  well-marked  degree  is  perceptible. 
In  adults  it  is  most  often  seen  in  those  who,  later  in  life,  are 
subject  to  attacks  of  rheumatic  gout;  and  its  importance  de- 
pends in  great  measure  on  the  warning  it  gives  of  this.  In 
itself,  it  is  merely  a  sign  that  the  joint  has  been  inflamed;  it 
means  nothing  more,  and  it  gives  no  indication  of  the  cause. 
But  subcutaneous  injuries,  such  as  sprains,  are  so  rarely  fol- 
lowed, in  young  and  healthy  adults,  at  any  rate,  by  this  com- 
plication that  when  it  does  occur  the  existence  of  some  addi- 
tional reason  is  always  to  be  suspected.  Occasionally  it  is  the 


Sprains ;  their  Consequences  and  Treatment.  205 

outcome  of  indiscretion,  or  of  some  mistaken  method  of  treat- 
ment ;  sometimes  it  is  due  merely  to  tension,  but  most  fre- 
quently when  inflammation  and  wasting-  follow  a  simple  strain 
there  is  a  history  of  gout  or  rheumatism,  or  both  together. 
The  injury  assists  the  constitutional  predisposition  by  selecting 
the  part  to  be  attacked,  and,  as  it  were,  antedates  the  out- 
break; in  after  years,  as  age  advances,  it  is  g-enerally  found 
that  assistance  of  this  kind  is  no  longer  required,  and  similar 
attacks,  producing  even  more  severe  degrees  of  wasting,  occur 
independently,  without  any  blow  or  strain  to  excite  them. 

I  have  known  this  happen  on  many  occasions.  The  patient 
g-enerally  gives  a  history  of  a  sprain  or  of  some  unusual  or 
sudden  effort  a  few  days  before.  Very  likely  nothing  is  felt 
at  the  time;  but  at  a  few  hours  later  there  is  a  sense  of  un- 
easiness and  stiffness  about  the  joint.  It  is  not  sufficiently 
severe  to  occasion  serious  anxiety ;  often  there  is  no  complaint 
about  it  until  the  question  is  asked;  but  yet  it  does  not  g-et 
well.  Then  quite  suddenly,  ten  days  or  a  fortnight  after  the 
accident,  the  condition  of  the  muscles  is  noticed  for  the  first 
time.  The  signs  of  inflammation  may  still  be  visible,  or  they 
may  have  already  passed  away,  leaving  the  wasting  and  a 
certain  degree  of  stiffness ;  there  may  be  a  sense  of  insecurity 
and  even  pain,  most  severe  at  night  and  when  the  joint  is 
moved,  or  some  distention  of  the  joint  cavity;  and  even  in  a 
few  instances  a  perceptible  rise  of  temperature,  or  there  may 
be  other  signs  of  what  has  been  quietly  g-oing  on;  but,  as  a 
rule,  they  are  so  slight  that  the  discovery  is  almost  accidental, 
and  the  diminution  in  size  is  thought  to  have  been  even  more 
rapid  than  it  really  is.  In  the  case  of  a  young  officer,  who  had 
strained  his  shoulder  while  wrestling  about  a  fortnight  before, 
I  was  solemnly  assured  that  the  wasting  had  come  on  in  the 
course  of  a  night. 

If  left  to  themselves  these  cases  sometimes,  but  not  often, 
recover  without  further  trouble ;  the  effusion  is  absorbed ;  the 
muscles  regain  their  tone;  the  stiffness  passes  off,  and  full 
movement  returns.  If,  on  the  other  hand,  whatever  may  have 
been  the  original  cause,  the  inflammation  does  not  very  soon 
subside,  the  changes  progress  and  become  exceedingly  serious. 
At  first  merely  the  extensor  muscles  and  the  lining  membrane 
of  the  joint  are  involved;  but  in  a  little  while  the  cartilage 
that  covers  the  ends  of  the  bones  and  the  bones  themselves  are 


206  Sprains ;   their  Consequences  and  Treatment. 

affected.  Absorption  takes  place;  the  length  and  axis  of  the 
limb  are  altered ;  symmetry  disappears ;  the  movements  lose 
their  smoothness  and  freedom ;  the  range  is  limited,  and  the 
muscles,  not  only  round  the  affected  joint,  but  also  those  of  the 
whole  limb,  become  atrophied.  Changes  of  this  nature  are 
most  often  met  with  after  middle  life  in  persons  with  a  strong 
tendency  to  rheumatic  gout,  but  they  are  not  confined  to  this 
period.  They  occur  as  well  in  young  adults,  and  are  some- 
times even  more  acute  in  them,  so  that  I  have  known  the 
lower  limb  lose  an  inch  of  its  length,  and  the  patient  become 
completely  crippled  ~by  the  pain  and  wasting  round  the  hip 
within  a  twelvemonth  of  its  having  been  sprained. 

Wasting  from  Overwork. — Atrophy  of  muscle  occasion- 
ally makes  its  appearance  after  prolonged  overwork,  and  even 
after  a  single  sudden  strain.  In  the  former  case  there  is  a 
great  tendency  for  the  wasting  to  spread  from  those  that  are 
first  involved  to  others;  and  when  this  occurs  definite  and 
well-known  changes  are  generally  found  to  exist  at  the  same 
time  in  the  cells  of  certain  regions  of  the  central  nervous  sys- 
tem. It  is  certain  that  there  is  a  connection  of  some  description 
between  overwork  and  these  pathological  changes,  but  it  is 
not  easy  to  say  how  close  this  may  be.  One  may  be  the  actual 
efficient  cause  of  the  other,  or  not  improbably  some  grave  con- 
stitutional disorder  may  be  the  real  agent,  and  the  overstrain 
merely  determine  the  particular  group  of  muscles  in  which  the 
changes  first  show  themselves.  However  this  may  be,  there 
is  no  question  that  the  exceedingly  serious  disorder  known  as 
progressive  muscular  atrophy  not  unfrequently  makes  its  first 
appearance  in  muscles  that  have  been  subjected  to  a  long  and 
continuous  overwork,  such  as  those  of  the  back  in  "  Ledgers 
and  ditchers." 

Wasting  from  a  Single  Strain. — Atrophy  due  to  one  sin- 
gle, sudden  effort  is  not  so  common.  I  have  seen  one  well- 
marked  case  in  which  the  muscles  of  the  upper  extremities 
were  involved.  The  patient,  who  was  a  man  of  good  muscular 
development,  had  slipped  suddenly  down  some  steps  while  car- 
rying a  heavy  weight  in  each  hand.  In  trying  to  save  himself 
from  falling,  he  made  a  sudden  and  vigorous  effort  with  his  arms, 
jerking  spasmodically  upward  the  weight  that  he  was  carry- 
ing.  The  shoulders  and  arms  were  stiff  and  painful  for  some 
time,  but  nothing  remarkable  was  noticed  for  about  three 


Sprains ;   their  Consequences  and  Treatment.  207 

weeks  or  a  month,  when  he  became  aware  of  loss  of  power  and 
of  wasting,  which,  when  I  saw  him,  was  so  extreme  as  to  con- 
vey the  impression  that  the  whole  substance  of  some  of  the 
muscles  had  disappeared.  The  affection  was  nearly  symmet- 
rical, that  is  to  say,  approximately  the  same  portions  of  both 
arms  were  attacked,  and  they  were  those  which  it  is  reasonable 
to  imagine  would  have  felt  the  strain  most  severely  in  such 
an  accident.  It  is  possible,  it  is  true,  that  the  wasting-  was 
secondary  to  the  severe  compression  sustained  by  the  nerves, 
as  they  run  down  into  the  arm  over  the  first  rib,  between  this 
and  the  collar-bone,  at  the  moment  of  the  fall.  Loss  of  power 
and  permanent  wasting1  of  the  muscles  are  sometimes  occa- 
sioned in  this  way,  as  Dr.  Vivian  Poore  has  shown,  though  as 
a  general  rule  such  momentary  compression  is  not  enough. 
It  must  be  continued  for  some  time  to  cause  so  serious  a  result. 
But  the  muscles  that  were  affected  in  this  particular  case  were 
too  distinct  and  isolated  to  admit  of  such  an  explanation. 
They  were  not  torn  in  any  way;  there  was  no  evidence  of  the 
nerves  being  injured.  There  was  no  loss  of  sensibility ;  the  pain 
was  not  severe;  there  had  simply  been  one  single,  sharp  con- 
traction; and  as  a  result  of  this  (or  at  any  rate  after  this)  the 
muscles  rapidly  wasted  and  lost  their  power.  Unfortunately, 
I  was  unable  to  watch  the  case  further,  and  so  cannot  say 
what  effect  galvanism  and  other  treatment  would  have  had, 
or  how  it  terminated  at  last.  I  should  think  it  not  improb- 
able that  it  ultimately  ended  in  the  progressive  form. 

Local  Wasting. — Liicke  has  described  the  same  thing  as 
occurring  in  the  great  extensor  muscle  on  the  front  of  the  thigh, 
from  the  effect  of  blows  or  sprains.  The  wasting  may  involve 
the  whole  of  the  muscle  or  only  a  part,  one  of  the  great  divis- 
ions, for  example,  of  which  it  is  composed,  or  a  smaller  portion 
still.  In  a  case  that  was  recently  under  my  care,  a  gap  could 
be  distinctly  felt  on  the  front  of  the  limb,  about  halfway  be- 
tween the  hip  joint  and  the  knee.  It,  gave  the  impression  that 
the  muscle  had  been  torn  across,  and  never  reunited,  though, 
according  to  the  patient's  statement,  which  was  quite  clear 
and  definite,  it  was  impossible  for  it  to  have  been  produced  in 
this  way.  The  gap  made  its  appearance  slowly  and  gradually 
after  a  strain,  nothing  being  noticed  for  some  days,  and  it 
kept  steadily  increasing  in  width  week  by  week.  Moreover, 
the  electric  reaction  of  the  whole  muscle  was  depressed,  and 


208  Sprains ;  their  Consequences  and  Treatment. 

there  was  a  general  loss  of  tone  and  firmness.  Liicke,  who 
has  thoroughly  gone  into  the  question,  has  come  to  the  con- 
clusion that  there  is  an  actual  loss  of  the  contractile  substance 
in  these  cases  similar  to  that  found  by  Valtat  in  the  atrophy 
following  inflammation  of  a  joint.  There  is  no  neuritis  or 
other  affection  of  the  nerves,  and  no  extravasation  of  blood ; 
the  wasting  may  follow  either  a  blow  or  a  strain;  and  its 
rapidity  is  in  no  way  measured  by  the  severity  of  the  injury. 
There  is  often  a  certain  amount  of  pain  of  a  rheumatic  char- 
acter, and  not  unfrequently  a  slight  amount  of  effusion  into 
the  knee  joint;  but  this  is  probably  passive  rather  than  active, 
allowed  to  take  place  by  the  relaxation  of  the  capsule  of  the 
joint  that  always  follows  loss  of  tone  in  the  extensor  muscles. 
According  to  the  same  authority,  atrophy  of  the  capsule  of 
the  joint  with  stiffness,  and,  at  a  later  period,  wasting  of  the 
other  muscles  of  the  leg,  are  not  unlikely  to  happen,  especially 
in  old  people. 

Muscular  Impotence  after  Strain. — Another  peculiar  con- 
sequence of  muscular  sprains  has  been  described  by  Duchenne 
under  the  name  of  functional  impotence.  It  cannot  be  called 
atrophy,  for,  in  the  earlier  stages  at  least,  no  gross  lesion  of 
any  sort  can  be  detected  either  in  the  nutrition  or  in  the  struct- 
ure of  the  muscles.  They  merely  become  tired  out,  and  give 
way  with  the  slightest  exertion,  so  that  the  joints  are  no  longer 
properly  supported,  or  the  bones  sufficiently  braced  together. 
Sometimes  this  is  the  effect  of  a  single,  sudden  strain;  more 
often  it  results  from  continuing  to  over-work  muscles  when 
they  are  weak  and  badly  nourished;  but  it  may  be  produced 
by  blows,  and  even,  it  is  said,  by  exposure  to  cold.  At  first 
there  is  only  an  indefinite  sense  of  pain  and  weakness,  but 
after  this  has  lasted  for  some  time  the  symptoms  become  more 
conspicuous.  If  there  is  the  least  exertion  the  affected  muscle 
is  thrown  into  a  state  of  rigid  spasmodic  contraction.  It  does 
not  relax  as  it  ought  to  in  its  proper  turn,  and  allow  the  joint 
to  move  smoothly  and  evenly,  but  remains  tense,  contracted, 
and  often  hi  a  state  of  painful  cramp.  This  lasts  longer  and 
longer  each  time  until  the  change  becomes  permanent;  the 
tendon  stands  out  under  the  skin  like  a  rigid  cord ;  the  sub- 
tance  of  the  muscles  wastes,  and  is  replaced  by  a  kind  of  fi- 
brous tissue  which  grows  shorter  and  shorter  until  the  joint  is 
fixed  in  one  position,  and  a  condition  is  produced  almost  iden- 
tical with  that  which  results  from  prolonged  inflammation. 


Sprains;   their  Consequences  and  Treatment.  209 

In  the  Spine.  Lateral  Curvature. — Functional  impotence 
of  this  description  occasionally  occurs  in  lateral  curvature  of 
the  spine ;  and  probably  is,  in  some  cases,  in  no  slight  degree 
the  actual  cause,  especially  when  the  deformity  sets  in  with 
great  rapidity  after  a  strain.  In  one  instance  under  my  ob- 
servation, the  patient,  a  boy  of  fifteen,  was  swinging1  by  his 
hands  from  a  horizontal  bar,  when  he  was  seized  with  sudden 
pain  running  round  the  abdomen  so  that  he  felt  sick  and  faint. 
After  lying  down  a  short  time  this  passed  off,  and  nothing 
further  was  noticed  until,  in  a  course  of  a  few  weeks,  his  back 
gave  way  to  such  a  degree  that  he  was  scarcely  able  to  hold 
himself  upright.  At  no  time  was  there  any  sign  of  inflamma- 
tion or  of  disease  of  the  bones;  there  was  no  bruising  or  ten- 
derness of  any  description,  so  that  nothing  could  have  been 
torn;  the  joints  were  uninjured  and  the  movements  perfect; 
only  the  muscles,  from  the  moment  they  had  been  strained, 
had  altogether  lost  their  strength.  By  a  vigorous  effort  after 
a  prolonged  rest,  they  were  able  to  get  the  back  nearly  straight 
again,  but  they  were  quite  unable  to  maintain  it;  almost  at 
once  they  began  to  relax  and  give  way.  There  was  no  serious 
alteration  in  their  structure,  for  under  proper  treatment  re- 
covery was  rapid  and  complete;  they  had  merely  lost  their 
power  as  the  result  of  one  single,  but  severe  strain.  Had  the 
case  been  left  to  itself,  there  is  little  doubt  the  deformity  would 
have  continued  to  increase,  and  ultimately  would  have  become 
permanent. 

In  the  Leg.  Flat  Foot. — Functional  impotence  is  still  more 
common  when  the  strain,  instead  of  being  momentary  like 
this,  is  kept  up  for  a  considerable  length  of  time  day  after  day. 
The  muscles  then  never  have  the  opportunity  of  thorough  rest 
and  relaxation ;  they  are  continuously  overtaxed ;  and  degen- 
eration, often  permanent  in  character,  is  very  likely  to  be  the 
result.  This  is  frequently  seen  in  the  common  form  of  flat 
foot  occurring  at  puberty.  Duchenne  has  shown  that  of  the 
arches  of  the  foot  the  long  one  is  maintained  almost  entirely 
by  the  action  of  certain  muscles  on  the  outer  side  of  the  leg, 
the  peronaei.  The  posterior  pillar  of  the  arch  formed  by  the 
heel  is  almost  vertical;  the  anterior,  made  up  of  the  bones 
which  form  the  great  toe,  is  long  and  slanting.  When  the 
weight  of  the  body  falls  on  the  crown  of  the  arch,  the  posterior 
pillar  is  fixed  by  the  pressure ;  the  other  would  slip  forward, 


2IO  Sprains ;  their  Consequences  and  Treatment. 

and  allow  the  arch  of  the  foot  to  sink  down,  if  it  were  not  for 
the  muscles  that  hold  it  back.  After  long-continued  standing-, 
kept  up  for  many  days  tog-ether,  for  many  hours  each  clay, 
these  muscles,  especially  in  a  growing  lad,  gradually  become 
tired  out  and  yield.  Then  the  tension  falls  on  the  ligaments, 
which,  like  all  such  structures  when  exposed  to  a  continuous 
strain  they  were  never  intended  to  bear,  stretch,  and  become 
the  seat  of  acute  pain,  spreading  up  either  side  of  the  leg. 
Finally,  they  give  way;  the  arch  of  the  foot  sinks,  and  the 
internal  border  becomes  proportionately  elongated.  If,  when 
this  stage  is  reached,  the  peronaei  muscles  are  examined,  the 
tendons  in  which  they  end  are  found  to  stand  out  like  rigid 
cords.  Under  the  influence  of  the  unceasing  strain  to  which 
they  are  unequal,,  they  have  passed  into  a  condition  of  perma- 
nent degeneration,  probably  identical  with  the  contracture 
that  followTs  inflammation,  and  now  by  their  shortening  form 
one  of  the  great  obstacles  in  the  way  of  recovery. 

I  must  not  be  understood  to  say  that  all  cases  of  flat  foot 
originate  in  functional  impotence  of  the  peronaei  muscles  caused 
by  overstrain;  but  I  am  quite  sure  this  is  the  chief  element  in 
a  very  large  proportion,  and  I  am  able  to  confirm  this  by  a  case 
of  my  own,  in  which  the  cause  of  the  loss  of  power  was  entirely 
different,  but  the  effect  the  same.  The  patient,  who  was  a 
strong,  athletic  young  man,  about  a  month  before  I  saw  him 
had  received  a  severe  blow  on  the  outside  of  the  leg,  immedi- 
ately over  the  middle  of  these  muscles.  No  especial  attention 
was  paid  to  it  at  the  time;  there  was  a  bruise,  and  that  was 
all.  But  in  two  or  three  days  he  noticed  that  walking,  and  to 
a  still  greater  degree  standing  upright,  caused  him  consider- 
able inconvenience.  This  grew  worse  and  worse,  until,  owing 
to  the  nature  of  the  trouble  from  which  he  was  suffering  not 
being  properly  understood,  he  was  reduced  to  such  a  condition 
that  he  could  scarcely  walk  six  steps  at  a  time.  The  pain  was 
so  intense  that  he  was  compelled  to  stop  and  lift  his  foot  off  the 
ground.  This  gave  instantaneous  relief,  but  the  moment  he 
rested  his  weight  on  it  again  all  the  old  suffering  returned. 
The  description  he  gave  was  exceedingly  clear.  At  first  there 
was  merely  a  general  and  ill-defined  sense  of  aching,  with  a 
feeling  of  pins  and  needles  running  down  the  outer  side  of  the 
leg;  then  his  foot  felt  tired  out,  especially  in  the  sole;  the 
aching  became  more  definite,  and  transformed  itself  into  a 


Sprains ;  their  Consequences  and  Treatment.  2 1 1 

dull,  numb  pain,  most  severe  behind  the  outer  ankle,  but 
spreading1  up  the  limb  as  high  as  the  knee.  The  longer  he 
stood  the  more  intense  this  became  and  the  wider  the  area  it 
involved,  until  he  was  literally  compelled  to  give  in,  and  raise 
his  limb  from  the  ground.  Throwing  his  weight  on  the  outer 
side  of  his  foot  enabled  him  to  walk  a  few  steps  further,  and 
he  always  affirmed  that  a  high-heeled  boot  enabled  him  to  get 
about  much  better  than  a  low  one. 

Careful  examination  made  it  plain  that  the  cause  of  all  his 
suffering  was  the  injury  sustained  by  this  particular  muscle. 
So  long  as  it  retained  its  natural  strength,  the  weight  of  the 
body  rested  on  those  points  of  bone  which  are  adapted  to  re- 
ceive it,  and  which  are  held  together  by  structures  propor- 
tioned to  the  strain.  The  arch  of  the  foot  was  as  perfect  as 
that  of  the  opposite  one.  But  when  in  a  little  while  the  mus- 
cle, unequal  to  its  work,  commenced  to  yield,  the  arch  lost  its 
main  tie,  and  the  anterior  pillar  began  to  slip  forward  until 
the  whole  of  the  strain  fell  on  the  ligaments,  stretching  them, 
and  causing  the  peculiar  sickening  pain  that  always  occurs 
under  these  conditions.  Fortunately,  in  this  particular  case,  the 
nutrition  of  the  muscle  was  restored  before  either  its  structure 
had  undergone  a  considerable  degree  of  degeneration,  or  the 
ligaments  had  been  seriously  stretched,  so  that  there  was  no 
serious  sinking  down  of  the  instep.  The  pain  was  naturally 
less  with  a  high-heeled  boot,  because  the  weight  was  then 
thrown  more  perpendicularly  on  the  anterior  pillar,  and  the 
strain  on  the  ligaments  was  lessened. 

Treatment. — The  treatment  of  this  complication  of  sprains 
requires  the  greatest  care  and  consideration.  It  may  be  de- 
pendent on  so  many  causes,  and  may  be  indicative  of  so  many 
different  pathological  conditions,  that  of  two  cases,  to  all  ap- 
pearance identical,  the  one  may  recover  easily  and  readily,  the 
other  may  be  merely  a  sign  of  the  commencement  of  some 
serious  disease.  The  first  thing  to  determine  in  all  cases  is 
whether  it  is  secondary  to  inflammation  or  not;  if  this  is  pres- 
ent nothing,  of  course,  can  be  done  directly  to  improve  the 
condition  of  the  muscles,  as  the  majority  of  the  remedies  em- 
ployed for  restoring  their  strength  and  activity  would  only 
tend  to  aggravate  the  disorder  of  the  joint.  As  soon  as  this 
has  passed  away,  there  is  nothing  peculiar  about  the  atrophy 
it  leaves,  except  the  ease  with  which  it  can  be  cured  in  the 


212  Sprains;  t/icir  Consequences  and  Treatment. 

earlier  stages,  and  the  extreme  difficulty  it  presents  in  the 
later  after  degeneration  has  set  in. 

Question  of  Inflammation. — The  best  evidence  that  in- 
flammation has  subsided  is  afforded  by  the  temperature  of 
the  skin,  as  compared  with  that  of  the  corresponding-  point  on 
the  opposite  side  of  the  body.  This  can  only  be  done  satisfac- 
torily by  means  of  a  surface  thermometer,  carefully  packed; 
the  hand  may  be  deceived,  but  this  scarcely  can.  The  points 
chosen  must  exactly  correspond,  they  must  be  under  the 
same  conditions  of  exposure,  and  the  rise  must  be  a  distinct 
one.  It  is  not  well  to  attach  too  much  importance  to  slight 
alterations  if  other  signs  are  not  present.  It  seems  as  if  cer- 
tain people,  by  directing-  their  attention  constantly  to  one 
part  of  the  body,  possess  the  power  of  raising  the  tempera- 
ture to  a  slight  extent,  probably  through  dilatation  of  the 
blood-vessels,  so  that  from  this  alone  it  becomes  slightly 
warmer  than  its  corresponding  area.  At  least,  I  have  on 
several  occasions  witnessed  phenomena  of  this  kind,  for  which 
I  could  find  no  other  explanation;  and  the  suggestion  is  quite 
consistent  with  what  is  known  of  the  influence  of  the  mind  on 
other  parts,  as,  for  example,  the  lungs  in  cases  of  phthisis. 
As  a  rule,  if  the  difference  is  inconsiderable  and  variable,  it 
may  be  taken  for  granted  that  inflammation  is  not  present; 
and  that  the  sooner  passive  movement  and  more  energetic 
treatment  are  adopted,  even  to  the  extent  of  forcibly  break- 
ing down  adhesions,  the  better  the  prospect  of  recovery. 

As  I  have  shown  already,  in  speaking  of  joints,  the  dan- 
ger is  that,  disregarding  the  positive  evidence  of  the  ther- 
mometer, and  relying  on  the  fact  that  movement  is  painful, 
it  may  be  imagined  that  inflammation  still  continues,  and 
that  further  rest,  with  its  inevitable  consequences,  further 
atrophy,  is  advisable  on  that  account.  The  mistake  is  the 
more  serious,  as  under  such  conditions  the  rigidity  is  con- 
stantly increasing,  so  that  the  prospect  of  recovery,  when  at 
length  an  attempt  is  made,  is  even  more  remote  than  it  was 
before. 

Local. — The  local  treatment  of  muscular  atrophy  is  foi- 
the  most  part  identical  with  that  which  has  been  described 
already  in  speaking  of  the  condition  of  disused  and  stiffened 
joints.  Everything  is  of  service  that  helps  to  exercise  them 
and  to  improve  the  circulation  through  them.  Passive  mo- 


Sprains ;  their  Consequences  and  Treatment.  213 

tion,  working-  each  of  them  alternately,  first  in  one  direction 
and  then  in  the  other,  sometimes  with,  sometimes  without  re- 
sistance; stretching-  them  out;  massag-e,  in  all  its  forms, 
especially  those  which  influence  most  the  deeper-lying-  strata; 
ironing-;  bathing-  and  douching-  with  hot  and  cold  water; 
shampooing-;  friction  with  stimulating-  liniments;  and  even, 
where  larg-e  masses  of  muscles  are  concerned,  as  in  the  back, 
acupuncture. 

Galvanism. — One  other  remedy  that  has  scarcely  been 
mentioned  yet  may  be  used  with  the  best  possible  result  in 
many  of  these  cases,  and  that  is  galvanism.  It  is  true  it  is 
impossible  for  any  one  who  is  not  a  specialist  in  the  subject 
to  undertake  to  form  an  elaborate  diag-nosis,  or  to  give  a  defi- 
nite opinion  as  to  the  extent  to  which  degeneration  has  spread 
in  particular  directions.  But  without  attempting-  this,  and 
even  leaving-  special  and  unusual  cases  aside,  there  is  no  in- 
considerable number  of  others  in  which  it  may  be  employed 
with  immense  benefit  under  the  g-uidance  of  simple  and  ordi- 
nary rules.  The  object  is  entirely  different.  It  may  be  impos- 
sible, without  special  education,  to  give  an  accurate  opinion 
from  the  electric  phenomena  alone  as  to  the  condition  of  the 
muscles,  and  the  probable  course  of  the  deg-eneration ;  but 
this  is  not  what  is  wanted.  The  diagnosis  has  been  made 
already.  It  is  known  from  other  S3Tmptoms  that  tho  atrophy 
is  the  consequence  of  certain  definite  causes,  such  as  inflam- 
mation, wrhich  may  or  may  not  have  ceased  to  exert  their 
influence.  This  is  sufficient  in  all  ordinary  cases.  Galvanism 
is  employed,  like  massage  and  other  remedies,  solely  as  a 
means  for  improving-  the  nutrition  of  the  tissue  and  restoring 
the  energy  to  the  muscles.  For  this  it  is  one  of  the  most 
valuable  applications  known,  and  if  only  there  is  a  fair  gen- 
eral knowledge  of  its  use,  and  the  method  of  its  employment, 
it  may  be  applied  in  a  very  large  number  of  cases  with  the 
greatest  benefit. 

In  Diagnosis. — It  has  been  thought  by  some  that  elec- 
tricity would  be  of  service  in  diagnosing  the  presence  of  hys- 
teria; that  by  its  means  it  would  be  possible  in  any  case  to 
ascertain  whether  the  loss  of  powrer  is  due  merely  to  loss  of 
will  or  to  some  actual  lesion.  If  this  were  so,  it  would  be  of 
the  greatest  use;  the  difficulty  is  a  common  one  and  often 
very  considerable.  But,  unhappily,  it  is  of  little  or  no  use  for 


214  Sprains ;  their  Consequences  and  Treatment. 

this  particular  purpose.  It  does  not  enable  us  to  discriminate 
in  any  definite  way  between  the  slighter  forms  of  traumatic 
or  pressure  paralysis,  and  that  which  is  met  with  in  hysteri- 
cal subjects.  When  the  atroplry  is  more  advanced,  and  the 
degeneration  plainly  marked,  the  signs  it  gives  are,  it  is  true, 
much  less  equivocal;  but  the  difficulty  then  has  in  great 
measure  disappeared,  and  the  diagnosis  may  be  allowed  to 
rest  with  safety  on  the  other  symptoms. 

The  Induced  Current. — Faradization  by  itself  is  required 
only  in  exceptional  cases.  Its  action,  even  when  applied  to 
the  muscles,  is  mainly  on  the  nerves  and  their  motor  ends, 
and  this  is  rarely  needed.  I  have  mentioned  one  remarkable 
case  in  which  it  proved  of  value,  restoring  to  full  use,  after  a 
third  or  fourth  application,  a  limb  that  had  been  almost  crip- 
pled for  over  a  twelvemonth.  There  was  apparently  some 
obstacle  to  the  transmission  of  stimuli  down  the  nerve  into 
the  muscle;  the  influence  of  the  will  was  not  sufficiently 
powerful  to  make  its  way  along  it.  One  set  of  muscles  was, 
in  consequence,  seriously  weakened,  and  the  opposing  ones, 
with  their  vigor  unimpaired,  kept  the  limb  constantly  con- 
tracted. Here  faradization  apparently  opened  up  the  path 
for  the  passage  of  other  stimuli,  so  that  full  power  of  move- 
ment was  regained.  Such  instances,  however,  in  the  absence 
of  hysteria,  are  not  common.  When  this  is  the  exciting 
cause,  faradization  often  proves  a  most  effectual  remedy,  but 
it  is  not  easy  to  say  in  such  circumstances  how  far  this  is  due 
to  moral  influences.  Apparent  paralysis  of  other  muscles,  at 
least  where  there  has  been  no  injury,  is  not  unfrequently 
cured  in  this  way. 

In  functional  impotence,  and  in  the  early  stages  of  the 
contracture  that  follows  it,  mild  direct  faradization  some- 
times restores  the  power  more  quickly  than  anything  else; 
but,  as  a  rule,  the  energetic  and  protracted  action  of  a  strong 
galvanic  current  answers  better.  Or,  if  a  more  powerful 
stimulus  is  desired,  the  positive  pole  may  be  applied  over  the 
muscle,  and  the  current  interrupted  occasionally,  and  even 
reversed.  I  have  had  no  experience  of  the  simultaneous 
action  of  the  galvanic  and  faradic  currents,  but  from  what  is 
known  of  the  refreshing  influence  of  the  former,  and  of  the 
power  it  possesses  of  increasing  the  electric  excitability  of  the 
parts  to  which  it  is  applied,  it  seems  reasonable  to  suppose 


Sprains;  their  Consequences  and  Treatment.  215 

that  it  would  be  of  material  assistance,  especially  in  cases 
such  as  these;  and  by  enabling  a  weaker  current  to  be  used 
would  avoid  the  fatigue  and  exhaustion  which  might  other- 
wise result.  The  alternate  action  of  the  two  is  certainly  very 
sucessful. 

The  Constant  Current. — For  atrophy  itself  galvanism  is 
more  effectual  than  the  interrupted  current.  It  is  a  mistake 
to  think  that  the  beneficial  effect  of  electrization  is  to  be  at- 
tributed in  any  way  to  the  production  of  muscular  contrac- 
tion. If  the  nerve  centres  of  the  spinal  cord  are  involved,  it  is 
impossible  to  prevent  degeneration  or  wasting.  The  influ- 
ence of  the  continuous  current  on  their  nutrition  is  to  be  at- 
tributed, rather,  to  its  chemical  action,  to  its  influence  on  the 
circulation,  and  to  the  way  in  which  it  promotes  the  absorp- 
tion of  waste  products  and  the  regeneration  of  broken-down 
elements.  As  I  have  already  pointed  out,  it  must  always  be 
remembered  that  the  nutrition  of  the  tissues  is  ultimately  de- 
pendent on  the  circulation  of  the  plasma  outside  the  walls  of 
the  vessels.  The  blood  circulates  in  these,  its  fluid  constituents 
passing  out  through  the  walls  and  permeating  the  tissues  in 
all  directions.  The  muscular  fibres  lie  embedded,  as  it  were, 
in  a  fluid  plasma,  which  requires  to  be  constantly  replaced, 
and  its  renewal  is  dependent  much  more  on  the  activity  of  the 
tissue  elements  themselves  than  on  the  mere  circulation 
through  the  vessels.  This,  without  the  other,  is  of  little  ser- 
vice. If  the  tissues  are  leading  an  active  and  energetic  life, 
the  circulation  of  the  plasma  is  carried  on  at  its  best;  if  they 
remain  sluggish  and  passive,  it  stagnates  round  them,  the 
part  is  badly  nourished,  and  the  tissues  become  sodden  and 
oedematous.  In  this  condition  of  things  regular  and  syste- 
matic employment  of  galvanism  is  especially  indicated. 
Whether  its  influence  depends  on  chemical  process  or  not,  it 
causes  the  swelling  to  disappear,  quickens  the  circulation, 
brings  back  the  color  to  the  skin,  and  restores  the  activity  of 
nutrition  in  a  manner  equalled  by  nothing  else.  Faradization 
may  be  used  in  certain  cases  and,  as  already  pointed  out,  is  of 
great  assistance  sometimes  in  conjunction  with  the  constant 
current;  but  so  far  as  muscles  are  concerned  in  everything 
beyond  the  mere  production  of  contraction,  the  latter  is  far 
the  most  useful. 

Generally  sneaking,  it  is  sufficient  that  the  limb  should  be 


216  Sprains ;  their  Consequences  and  Treatment. 

galvanized  every  other  day,  alternating  it  with  massage  for 
five  or  ten  minutes  each  time.  In  certain  cases  it  may  be 
used  more  frequently,  but  there  is  often  a  tendency,  especially 
on  the  part  of  the  patients,  to  over-galvanize  the  limb.  Dis- 
appointment must  not  be  felt  if  it  is  some  time  before  any  de- 
cided improvement  makes  its  appearance.  The  regeneration 
of  the  tissues  must  be  a  slow  process;  absorption  and  nutri- 
tion may  be  assisted,  but  they  cannot  be  hurried. 

The  strength  of  the  current  should  always  be  moderate, 
though  it  is  difficult  to  lay  down  any  definite  rules.  It  is  not 
possible  to  be  accurate  without  the  aid  of  delicate  and  compli- 
cated instruments.  Specifying  the  number  of  cells  gives  little 
or  no  idea;  allowance,  for  example,  must  be  made  for  differ- 
ence in  the  resistance  of  the  skin  in  different  parts  of  the  body. 
Where  it  is  thin,  or  where  there  is  a  large  number  of  sweat 
glands,  the  current  passes  much  more  easily  than  it  does  else- 
where; and  the  resistance  diminishes  with  moisture,  with 
pressure,  and  with  the  length  of  time  the  current  is  applied,  this 
being  due  in  all  probability  to  the  fact  that  after  it  has  been 
passing  some  time  the  blood  circulates  more  freely  through 
the  superficial  parts.  It  should  never  cause  the  least  suspi- 
cion of  pain;  if  actual  contraction  is  desired,  each  muscle  must 
be  stimulated  in  turn  by  applying  the  electrode  to  its  motor 
point  or  points,  as  the  case  may  be;  or  if  the  nerve  that  sup- 
plies the  muscle  is  more  easily  accessible  contraction  may  be 
produced  in  this  way,  but  the  weakest  current  that  will  effect 
this  must  always  be  used.  In  the  case  of  galvanism  the  size 
of  the  electrodes  is  a  most  important  consideration.  The 
strength  of  current  passing  through  the  body  from  a  certain 
number  of  cells  is,  other  things  being  equal,  dependent  on  the 
extent  of  their  surface.  Consequently,  where  there  are  large 
masses  of  muscle,  as  in  the  back,  and  where,  accordingly, 
large  plate-like  electrodes  are  employed,  a  current  of  propor- 
tionate strength  should  be  used.  If  they  are  large  enough, 
and  kept  well  moistened,  there  need  be  no  fear  of  injuring  the 
skin. 

When  galvanism  is  used,  for  its  refreshing  action,  after 
faradization  or  to  relieve  the  sensation  of  fatigue,  the  positive 
pole  should  be  applied  to  a  point  more  distant  from  the  trunk 
than  the  negative  in  order  to  obtain  as  far  as  possible  an 
ascending  current.  In  other  circumstances  the  cathode  is 


Sprains ;  their  Consequences  and  Treatment.  217 

placed  directly  over  the  structure  it  is  intended  to  galvanize, 
and  either  held  there  or  slowly  moved  over  in  the  direction  of 
the  fibres.  The  latter  method  is  much  more  stimulating ;  the 
current  is  always  var37ing  in  intensity,  being  most  vigorous 
immediately  under  the  electrode,  and  the  energy  with  which 
it  acts  upon  the  muscles  beneath  is  constantly  changing  as  it 
moves  over  their  surface;  so  that  in  addition  to  the  chemical 
influence  it  possesses  it  calls  out  moderate  contration  of  all 
the  fibres  in  turn.  The  rapidity  of  the  movement  is  as  impor- 
tant in  determining  the  amount  of  muscular  contraction  as 
the  strength  of  the  current,  owing  to  the  suddenness  in  the 
variation,  when  the  position  of  the  electrodes  is  changed. 

Even  when  there  is  no  atrophy  galvanism  has  a  very  ben- 
eficial influence  on  sprains  in  their  later  stages.  The  action 
of  the  muscles,  perhaps,  is  embarrassed;  every  movement  is 
attended  by  a  sense  of  stiffness  and  fatigue;  the  tissues  are 
rather  swollen;  the  skin  feels  cold,  and  the  muscles  do  not 
respond  readily.  The  injury  has  been  repaired,  it  is  true,  and 
there  is  no  definite  alteration  in  the  structure  of  the  part,  but 
it  does  not  perform  its  function  properly,  and  recovery  is  not 
perfect.  The  circulation  requires  a  stimulus;  the  conducting 
power  of  the  nerves  is  enfeebled;  the  muscles  need  educating 
again,  as  it  \vere;  their  contraction  is  not  orderly,  as  it  should 
be;  they  do  not  assist  each  other,  and  the  movement  is  not 
passed  on  from  one  to  the  other  as  smoothly  and  evenly  as 
it  is  in  health;  the  result  is  a  sensation  of  pain,  wrhich  pre- 
i-ents  freedom  of  action,  and  by  encouragng  the  patient  to 
keep  the  part  at  rest  delays  convalescence  more  and  more. 
Under  these  conditions  the  thorough  electrization  of  the 
whole,  using  the  interrupted  and  constant  currents  alter- 
nately, often  effects  a  cure  in  a  very  short  space  of  time,  es- 
pecially if  it  is  assisted  Toy  massage.  Nothing  restores  power 
and  freedom  of  movement  more  easily  or  more  quickl}7.  If  it 
fails,  and  there  is  no  serious  disease  or  inflammation  to  ac- 
count for  the  persistence  of  the  symptoms,  the  presence  of  some 
adhesion,  too  strong  to  give  way  before  such  mild  measures, 
is  to  be  suspected,  and  it  becomes  advisable  to  examine  the 
joint  under  an  anaesthetic. 


INDEX. 


ABSORPTION,  66-67 

of  effusion  in  sprains,  66 
Accidental  bone-setting,  112 
Acupuncture  in  treatment  of 

sprains,  168 
Adhesions,  108 

in  joints,  74 

treated  by  division,  109 

treated  by  manipulation,  110 
Adults,  tonic  contraction  in,  192 
Age,  effect  of,  on  joints,  27 

effect  of,  on  tendons,  134 
Anaesthetics,  advantages  of,  31 
Anatomy  of  joints,  9 
Arnica  in  sprains,  87 

BACK,   dislocation  of  muscles   in 

the,  56 

dislocation  of  tendons  in  the,  56 
injury  to  the  bones  of,  157 
injury  to  the  smaller  joints  of, 

157 
sprains  of,  152 

Baths  in  treatment  of  strains,  164 

Biceps,  displacement  of,  58 

Bones,  11 

injury  to,  59 

of  the  back,  injury  to,  157 

Bursa,  Rider's,  50 

Bursae,  44 

CAPSULE,  11 

Cause  and  prevention  of  sprains,  18 

Children,  tonic  contraction  in,  190 

Chronic  sprains,  23 

Cold  as  a  temporary  application,  85 
continuous  application  of,  86 
in  treatment  of  sprains,  83 
method  of  application  of,  85 

Compound  ganglion,  149 

Compression  as  muscle  degenera- 
tor.  202 

Contraction,  muscular,  187 
of  the  fingers,  179 

Cramp,  187 

Creaking  in  joints,  74 

DIAGNOSIS,  30 

galvanism  in,  214 

Difference  between  male   and 
female  skeletons,  22 


Discoloration,  34 

Dislocation  of  muscles  of  the  back, 

159 

of  tendons  and  muscles,  55 
Dislocations,  36 
Distention  of  tendon  sheaths,  etc., 

61 

Division,  adhesions  treated  by,  109 
Dry  synovitis,  79 
Dupuytren's  contraction,  179 

EFFECT  of  age  on  joints,  27 

of  muscular  development,  21 

Effusion  and  distention,  61 
in  sprains,  61 

Elbow,  dislocation  of,  in  children, 
34 

Exercise,  manipulation  as  an,  117 

Extensor  muscles,  wasting  of,  203 

FARADIZATION  in  muscle  atrophy, 

214 

Feebleness  of  muscular  system,  25 
Fibrous  tissue,  12 
Finger  contraction,  cause  of,  180 
Fingers,  contraction  of  the,  179 

injuries  of  the,  47 
Flat-foot,  209 

treatment  of,  211 

Forcible  manipulation    in    treat- 
ment of  sprains,  108 
Fractures,  38 
Friction,  122 

in  treatment  of  sprains,  122, 166 

GALVANISM  in  diagnosis,  214 

in  treatment  of  muscle  atro- 
phy, 214 
in  treatment  of  sprains,  168 

Ganglion,  compound,  149 

Ganglions,  148 

HAND,  displacement  of  tendons  on 

the,  58 
Heat  in  treatment  of  sprains,  88, 

163 

Hemorrhage,  42,  43 
Hypersemia  and  softening,  61 
Hyperaesthesia  in  sprains  of  the 

back,  156 


22O 


Index. 


IMPAIRMENT  of  mobility,  73 
Imperfect  recovery,  71 
Impotence,  muscular,  after  sprain, 
208 

muscular,  in  the  leg,  209 

muscular,  in  the  spine,  209 
Inflammation,  60 

in  muscles  a  cause  of  wasting, 
104 

in  sprains  of  tendons,  139 

question  of,  212 
Injuries  of  the  fingers,  47 

of  the  spinal  cord,  153 

to  bones,  59 

to  the  muscles  of  the  back,  154 

to  the  sheaths  of  tendons,  138 
Injury  of  the  knee,  47 

of  the  ligaments,  45 

of  the  muscles,  48 
Ironing  in  treatment  of  sprains,  167 

JOINT  disease,  simulation  of,  193 

interior  of  the,  78 
Joints,  anatomy  of,  9 

changes  in  the  tissues  of,  77 

effects  of  age  on,  27 

effects  of  prolonged  rest  on,  98 

movable,  10 

neuralgia  of  the,  80 

stiffness  in,  63 

yielding,  9 

KNEE,  injury  of  the,  47 

internal  derangement  of,  172 

LATERAL  curvature  of  the  spine, 

209 
Lawn-tennis  arm,  137, 

leg,  51 
Leg,  muscular  impotence  in  the, 

209 
Ligaments,  13 

of  the  back,  158 

of  the  back  and  neck,  injury 

to,  154 
injury  of,  45 
Liniments  in  treatment  of  sprains, 

166 

Local  measures  for  relief  of  sprains, 
163 

MANIPULATION,  adhesions  treated 
by,  111 

as  an  exercise,  117 

forcible,   in    treatment    of 
sprains,  98,  108 

rapid,  method  of,  116 

rapid,  preparation  for,  115 
Massage,  120,  124 

in  injuries  not  recent,  127 

in  recent  injuries,  126 


Massage  in  treatment  of  muscular 
pains,  168 

in    treatment  of  sprains,  120, 
144,  168 

in  treatment  of  tendon  sprains, 
144 

method  of  application  of,  127 
Mobility,  impairment  of,  73 
Movable  joints,  10 
Movement  and  inflammation,  102 

in  treatment  of  sprains,  102, 146 

passive,  103 

time  for,  104 
Muscles,  condition  of  the,  18 

degeneration  of,  from  compres- 
sion, 202 

degeneration  of,  from  disuse, 
201 

dislocation  of,  55 

injuries  of  the,  48 

of  the  back,  158 

of  the  back  and  neck,  injury 
to,  154 

of  back,  dislocation  of,  159 

wastingof,  from  inflammation, 
204 

wasting  of,  from  overwork,  206 
Muscular  contraction,  187,  198 

impotence  after  strain,  208 

impotence  in  the  leg,  209 

impotence  in  the  spine,  209 

pain,  161 

pain,  general  treatment  of,  163 

rigidity,  73 

strains,  137 

wasting,  201 

NATURE  of  the  injury,  40 
Neck,  sprains  of,  152 
Neuralgia  after  sprain,  80 
of  the  joints,  80 

ORGANIZATION  between  muscles, 

64 

not  due  to  inflammation,  65 
of  tissue,  62 
of  tissue  in  bursae,  64 
of  tissue  in  joints,  63 
Overwork,  a  cause  of  muscle  atro- 
phy, 206 
effects  of,  on  tendons,  135 

PAIN,  34- 

muscular,  161 
Paralvsis  in  sprains  of  the  back, 

156 
Passive  movement  in  treatment  of 

tendon  sprains,  145 
Percussion,  123 

in  treatment  of  strains,  169 


Index. 


221 


Permanent  changes  following  ten- 
don sprains,  146 
changes  in  substance,  68 
Peronsfii  tendons,  displacement  of, 

57 
Pressure,  effects  of,  68 

in  treatment  of  sprains,  91 
in  treatment  of  tendon  sprains, 

144 
Prevention  of  sprains,  18 

RAILWAY  spine,  156 

Rapid  manipulation,  preparation 

for,  115 
Recovery,    imperfect,    of    tendon 

sprains,  140 
Rest,  97 

in  treatment  of  sprains,  0 ,' 
prolonged,  changes  in  tissues 

due  to,  99 
prolonged,  effects  of,  on  heaithy 

joints,  98 
Rider's  bone,  120 
bursa,  50 
sprain,  49 

Rigidity,  muscular,  73 
Ruptured  veins,  59 

SARTORIUS,  dislocation  of  the,  56 
Semilunar  cartilages,  displacement 
of.  173 

cartilages,  ruptures  of,  173 
Skin  in  sympathy  with  parts  be- 
neath, 20 

Softening  of  vessels,  61 
Soreness,  34 
Spinal  cord,  injuries  of,  153 

injuries  of,  by  sprains,  153 
Spine,  lateral  curvature  of  the,  209 

muscular  impotence  in  the,  209 

railway,  156 
Spongiopilinein  treatment  of 

cramp,  189 
Sprains  and  dislocations,  36 

and  fractures,  38 

cause  and  prevention  of,  18 

chronic,  23 

diagnosis,  30 

effusion  in,  61 

forcible  manipulation  in  treat- 
ment of,  108 

general  considerations,  5 

imperfect  recovery  in,  71,  140 

inflammation  and  the  process 
of  repair,  60 

massage  in  treatment  of,  120, 
144,  168 

nature  of  the  injury,  40 

neuralgia  after,  80 

of  tendons,  133 

of  the  back,  152 


Sprains  of  the  neck,  152 

of  the  back  and  neck,  152 
prevention  of,  18 
treatment,  82,  142,  163 

Strains,  161 

muscular,  137 
treatment  of,  163-171 

Structure  of  the  fingers,  179 
of  tendons,  133 

Swelling,  32 

Sympathy  of  parts,  15 

Synovia!  membrane,  14 

Synovitis,  dry,  79 

TEXDERXESS,  34 

Tendon  sprains,  treatment  of,  142 

Tendons,  dislocation  of,  55 

effect  of  overwork  on,  135 

effects  of  age  on,  134 

extent  of  injury  to,  135 

injury  to  the  sheaths  of,  138 

sprains  of,  133 

structure  of,  133 
Tenosynovitis,  136 
Thumb,  sprain  fracture  of,  38 
Time  for  repair,  69 
Tissue  starvation,  80 
Tonic  contraction,  190 

contraction  in  adults,  192 

contraction  in  children,  190 
Treatment,  97 

general,  of  muscular  pain,  lc;'> 

of  finger  contraction,  182 

of  sprains,  82 

of  sprains  by  application   of 
cold.  83 

of  sprains  by  application    of 
heat,  88 

of    sprains  by  application   of 
pressure,  91 

of  tendon  sprains,  142 

of  tendon  sprains  by  massage, 
144 

of  tendon  sprains  by  passive 
movement,  145 

of  tendon  sprains  by  pressure, 
144 

WARMTH    for  relief  of  muscular 

pain,  163 
Wasting,  muscular,  201 

of  extensor  muscles,  203 

of  muscles  from  compression, 

202 
of  muscles  from  inflammation, 

204 

of  muscles  from  overwork,  206 
Whole  limb  should  be  carefully 
examined,  31 

YIELDING  joints,  9 


Date  Due 


DEC  7 


1970 


CAT.    NO.   23   233  PRINTED    IN    U.S.A. 


000510470 


WE175 
M926s 

Moullin. 

Sprains;  their  consequences 

and  treatment 


WE175 
M926s 

1891 
Moullin. 

Sprains;  their  consequences  and 
treatment 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


